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Dr. Carrie’s

CRASH COURSE ON CONSTIPATION

▪ STOOL FREQUENCY IS NOT A RELIABLE INDICATOR OF THE PRESENCE OR ABSENCE OF CONSTIPATION

WHAT ARE THE SIGNS AND SYMPTOMS OF CONSTIPATION? Some of the most common manifestations of constipation are the following: (remember, every child is different; any given child may have only one, any combination, or all of these. Also, the clinical picture may change over time)

▪ Abdominal pain

o Typically described as crampy and often occurs within 1-2 hours of a meal

o The pain comes and goes-- after a period of intense pain, it begins to remit, and the child might feel perfectly fine until the next bout of pain strikes.

▪ Diminished appetite (this may fluctuate)

▪ Small, firm balls of stool, looking like “rabbit pellets”

▪ Sensation of the urge to poop, along with inability to get any or all of it out—“it’s stuck!”

▪ Larger than normal poops; sometimes they are so big they are difficult to flush

▪ Encopresis—(“SKID MARKS”) leakage of small amounts of stool into underwear. This happens because a hard, large clump of poop is stuck in the rectum. Even though it can’t get it all out, the body keeps making poop, so liquid poop oozes out, around the big stuck poop. Because the rectum is so stretched from the stuck poop, the child often cannot feel the urge to poop, and does not even know poop has leaked out until she either sees it in her underwear or smells it!

▪ So watery poop in this situation reflects constipation, despite looking like diarrhea, especially if it is leaking out into underwear.

▪ Urinary symptoms, including increased frequency of urination and/or urinary incontinence (either during the day or at night).

▪ PART TWO, MANAGEMENT: This plan is intended for families of children who have been evaluated in our office and diagnosed with constipation, and for whom we have specifically recommended the plan.

If you have ANY questions, or if at any time you feel your child is worse, PLEASE STOP AND CALL your doctor.

➢ Treating constipation is not a quick-fix, one visit process! In order to relieve the discomfort and to prevent the complications of constipation, we need to work toward the goal of at LEAST 1 soft, non-painful poop every day.

➢ In the process of reaching this goal, we will need to cause some loose, watery stools in order to loosen up and evacuate the poop that is “stuck” in there.

➢ IT IS GOING TO LOOK LIKE DIARRHEA. THAT MEANS IT IS WORKING.

➢ Once the colon is cleaned out, and your child continues to evacuate stool at the rate at which it is formed, the colon can gradually return to its normal size, shape and function. Once the colon has returned to normal, with continued regular BM’s, eventually the problem will be gone.

For reasons we can discuss at greater length during an appointment in the office, I do not recommend the routine use of either enemas or stimulant laxatives (e.g. Senokot) in children. If your child needs either of these, we can discuss it in depth during your visit.

TOOLS FOR TREATING CONSTIPATION

Miralax: an over-the-counter stool softener, which is VERY SAFE. By osmotically pulling water into the colon, Miralax softens the stool, making it easier and less painful to pass. Miralax works directly in the GI tract, and does not get absorbed into the bloodstream. It is really a STOOL SOFTENER, not a “laxative” and does not cause the intestinal muscles to contract. It is not “addictive” and will not make your child’s constipation worse, no matter how long he needs it.

• Most kids with your child’s degree of constipation require Miralax daily for at least 2-3 months. When the plan is stopped prematurely, the child will almost inevitably have a recurrence of the problem; that is, he or she will stop getting out poop at the rate it is formed, will get backed up again, and the painful poops and abdominal pain will recur.

➢ IF MIRALAX IS NOT “ADDICTIVE”, THEN WHY DO WE HAVE TO USE IT FOR SO LONG? ALSO, WHY DOES SHE GET CONSTIPATED AGAIN SHORTLY AFTER WE STOP GIVING HER THE MIRALAX?

• The reason that kids “need” Miralax for what seems like such a long time is NOT because they are “addicted to” or dependent upon the Miralax. Instead, it is because the constipation has caused the rectum to stretch /dilate and to function abnormally.

• The goal of treatment is to evacuate the stool, thereby allowing the colon and rectum to return to normal size, shape, and function. When this is accomplished, medicines will no longer be needed, as long as the child can continue to get the poop out at the rate at which it is formed.

Glycerin suppositories: another over- the-counter medicine that is great for the initial cleanout phase. The suppositories loosen up hard stool that is stuck in the rectum. Getting this “plug” out his makes it easier for the rest of the stool (which is being softened up by the Miralax) to come out.

STEP ONE- “CLEANOUT”: MIRALAX: please give ONE capful of Miralax TWICE a day, one in the morning and one at night. Each dose should be mixed well in 8 ounces of liquid. If you mix it in juice or other flavored liquid, the child will not be able to taste it!

• GLYCERIN SUPPOSITORIES: following the package directions in terms of dose, insert the appropriately-sized suppository into the rectum before supper tonight.

• Make sure your child is getting plenty of oral liquids during this phase. You will know that he or she is adequately hydrated if there is urination at least every 6-8 hours.

• The goal of the cleanout phase is several watery-to-loose stools daily.

• Remember, it is going to look like diarrhea. That means it is working.

➢ If you get a good result over the next 24 hours, using the combination of the first dose of glycerin suppository and the Miralax, it is highly unlikely that your child will require suppositories after the initial cleanout phase.

➢ If your child is still constipated on the 3rd day of the plan (for example, he or she still has poop balls or painful poops), then use glycerin suppositories every other night until the cleanout is well underway, that is, when the daily poops are all very soft and/or watery.

• The cleanout phase is over when the loose and watery poops become more formed and more like “normal” poop. This will happen! As the cleanout progresses, the watery poops will seem less like “diarrhea” and have a more normal consistency while you are still giving the twice-daily Miralax. If your child is still having loose watery poops after 7 days of twice-daily Miralax, cut Miralax back to once a day and make an appointment to see me.

STEP TWO- “FINDING YOUR CHILD’S MAINTENANCE DOSE OF MIRALAX”

• At this point, your child should be having at least one very soft, non-painful poop every day. Two or more would be better!

• NOW, decrease the dose of Miralax to ONE-HALF capful of Miralax twice a day.

• Continue at this dose for 2 full weeks. IF ANY signs or symptoms of constipation return, then go back to step one.

• If poops are daily, soft, and your child is pain-free after these 2 weeks of taking twice-daily Miralax at a dose of __1/2 capful, you are ready to move on with the plan! HOWEVER, please make an appointment to see me as soon as possible if:

o poops are still very watery at this stage, or

o Your child has abdominal pain, urinary symptoms, or any other problems.

• *Next, keeping the amount the same, at 1/2 capful, decrease the frequency of Miralax to ONCE DAILY.

• **After one week at this dose, try to decrease even more, giving only about 1/4 capful ONCE daily.

• Again at this point, if ANY symptoms of constipation return, go back to *, i.e., increase Miralax dose back to 1/2 capful once day for 1 more week.

o At the end of this 1 week period, proceed from there (i.e. go back to **: and try to cut back down to 1/4 capful again.

• Continue this cycle until the child has been taking 1/4 capful, once a day for 2 weeks, without any problems whatsoever, and without any sign that constipation is recurring.

STEP THREE- “NO MORE MEDS!”

• *** After 2 weeks on ___1/4 capful once daily, if your child is having soft stools at LEAST once a day, with no pain, no blood, no little poop balls, and no problems, try to stop Miralax.

• Watch closely, communicating frequently with your child about his/her poops.

o While you are not giving Miralax, if he or she goes for a day without any poop at all, or if there are signs of returning “constipated” poops (huge and painful, or little poop balls, etc.), go back to ***, giving _____1/4 capful once daily for 2 weeks.

• Keep going with the plan until he or she is having non-constipated poops, every day, without medicines.

• Continue to pay close attention for any signs that constipation is recurring!!!

Other tips:

▪ Good nutrition, including drinking plenty of water and consuming age-appropriate amounts of fiber, fruits and vegetables, is always a healthy idea. However, if you are receiving this handout, your child also needs a stool softener. It is HIGHLY UNLIKELY that dietary interventions will make a significant difference in your child’s symptoms, unless dietary changes are made along with the cleanout plan.

▪ Explain to your child as clearly as possible that the only way to make this problem (the stomach pain, the painful stools, etc.) go away is to get the poop out. Holding it in will make it hurt worse. Push it out!

o This is counter-intuitive! That is, usually the best thing to do is to stop doing whatever causes the pain. For example, if you burn your hand touching a hot stove, you quickly withdraw your hand from the hot burner.

o With constipation you must do the opposite. It is critical that we persuade kids to keep sitting on the toilet and to keep pushing and trying to poop even when it hurts a little.

▪ On the other hand, because of the stool-softening effect of Miralax (and glycerin suppositories in step one), the pain while defecating should not be severe. If it is continues to be very painful to get the poop out, please see me in the office.

• Also, even if the poop IS properly softened at this point, many kids continue to withhold stool, either by habit or from fear that the pain will return.

▪ Part of the problem with constipation is that it is a vicious cycle. When pooping hurts, a child logically tries to hold it in. Unfortunately, stool withholding only makes the stool bigger and harder, so the pain will only get worse unless the poop comes out!

▪ The sooner this cycle is broken, the sooner your child will be better!

▪ If your child ever has vomiting, fever, or blood in the poop, CALL your doctor.

▪ It will work- with time and patience. If you have questions, call your doctor.

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