Four and a half-year-old Melissa started pre-kindergarten last fall. She goes to school five days a week, half days, getting home at noon. According to mom she enjoys school and is getting along very nicely. Melissa was brought to the office because of stomach aches and what mom thought might be constipation.
The child was fully potty trained after she was two years old and never had any problems…until school started. She eats a well- balanced diet, does not drink much milk and does not like cheese. The stomach aches occur intermittently. They are never severe, nor do they wake her at night. There is no soiling (encopresis) nor has mom ever seen or heard of any blood on the toilet paper after she wipes. Normally Melissa has a bowel movement every other day and is in the bathroom a long time.
Melissa seemed to be a happy child with a bubbly and outgoing demeanor. She did not have a fever nor was there a fever in the past. Her weight and height are completely normal with normal bowel sounds. I did not appreciate any abnormal masses. However, I did feel some stool in the left lower quadrant. I inspected the peri-anal area, seeing no hemorrhoids or fissures (tiny tears that can be from undue straining). She had a normal exam.
Upon further questioning it seemed that before Melissa started school she would normally have a bowel movement in the mornings, like clock-work. This changed once school started. Now there was no consistent pattern to her bowel habits other than she was not going daily, and she took a long time when she would go. Mom checked the stool from time to time. While they were very large and hard she saw no blood.
It is important to determine if one is really constipated. A person can have a bowel movement every other day but not be constipated as long as the stool is soft and easy to pass. On the other hand, a person can be terribly constipated, yet have liquidy stools two or three times a day, even with leakage and accidents (encopresis).
In Melissa’s case I think she was truly constipated. I surmised that what started this was her not wanting to go to the bathroom at school, holding it, and waiting until she got home. The urge then passed and the stool accumulated in the rectum. When she felt the urge to go again the stool was large and hard, probably uncomfortable to pass. She would then subliminally associate bowel movements with discomfort and hold it again. This pattern would promulgate itself which could lead to fissures from the straining, little tears in the peri-anal area that are like tiny paper cuts. These tears can be painful and lead to some bleeding of bright red blood, usually on the toilet paper after wiping. Again pain is reinforced with bowel movements and further worsens the situation. I did not see any fissures when I checked Melissa.
When asked about school Melissa said she does not like to go to the bathroom there and holds it until she gets home, just as I had suspected. When she goes to the bathroom at home and sits on the toilet, can she plant her feet on the floor? Mom thought about it. No, her feet dangle about three inches from the floor. Given that, I thought we had a good plan to take care of this constipation.
I wanted mom to get a foot stool that Melissa could use when she sits on the toilet. Most kids at this age cannot plant their feet on the floor when they sit on the toilet. As a result, most of their energy is spent in balancing themselves. They are not afforded the luxury of fully using their abdominal muscles to strain and bear down to have an effective bowel movement. Mom thought about it, nodded, and said, “Makes sense”.
Melissa should get adequate fluids. She could have apple juice or pear juice to help soften the stools. These are not great calories from a nutritional standpoint, but they both have high concentrations of sorbitol which is a heavy sugar that pulls water into the stool and thus softens it. These juices are only to help soften the stool and should be used as such. Mom was instructed to essentially “titrate” or adjust the amount of juice she gave her to insure soft stools. In other words, she could give Melissa four to six ounces a day. If this worked and Melissa was having daily, soft stools, they could cut back to every other day. This was a dynamic issue and the amount of juice needed would vary from day-to-day. If she was having loose stools, she would need to cut back accordingly. We went over her diet to insure that Melissa was getting adequate fiber.
If this regimen did not produce the desired results, and Melissa was still constipated she could get some Miralax, or polyethylene glycol at the market. This is a non-prescription powder that is sold at most pharmacies or local markets. It is a powder that readily dissolves in almost any liquid and is not gritty, therefore easy to drink. It is very osmotic. As it passes through the colon it pulls water into the stool and helps make it soft. It comes with a measuring cap; one capful contains 17 grams of the powder. Everyone’s dose of Miralax varies and can change with time. If she needed to use this for Melissa she should start with ¾ of a capful in six ounces of fluid daily. She would then need to titrate the dose daily to insure soft and easy to pass stools. I warned her that she may need to adjust the dose quite frequently.
Both mom and Melissa seemed pleased with this plan. She was told to keep a diary over the next two weeks after which I would see them back for a re-check. As a parting shot, I told mom not to fret, that “…This too shall pass”, which she found humorous. When they came back for the follow-up, mom was pleased to report that she didn’t need to use the Miralax. In fact, the foot stool made a big difference. Melissa was able to go to the bathroom most mornings before school, just like before. As for the juices, she was using these sparingly.