Constipation Care Plan

Constipation Care Plan

McKenzie Pediatrics, P.C.

Child’s Name: ___________________________________________ DOB: ___________________ Date of Plan: __________________

What Are The (Many) Definitions of Constipation?

• Recurrent painful passage of stools for greater than 2 weeks at any age
• Fewer than 3 stools per week in a child greater than 1 year of age
• More than 4 days without a stool in a child greater than 1 year of age, or for more than 7 days in an infant
• The inability in an older child to pass stools despite the urge, discomfort, or pain

What Is NOT Constipation?

• Large bowel movements at regular intervals without pain or straining
• Regular soft stools in an infant with straining. Infants often strain, grunt, pull up their legs, and become red in the face with stooling. It can be difficult for a baby to coordinate the passage of stool, especially when laying down!
• Soft stools that are passed without pain or straining but only every 2-3 days

What Are Possible Causes (or Combinations of Causes) for Childhood Constipation?

• Inadequate amounts of fluid intake over days, weeks, or months. More common during the hotter months.
• Inadequate dietary fiber intake (not enough fresh fruits & vegetables!)
• Over abundance of starchy foods (especially processed carbohydrates such as breads & pastas) in the child’s diet
• Over abundance of dairy products in the child’s diet (most children are lactose intolerant by age 10)
• Voluntary withholding of stool for fear of a painful bowel movement, due to a past painful bowel movement. This is most common in toddlers and pre-school aged children.
• Forced toilet training, leading to anxiety and tension, or voluntary withholding as a way to exert control.
• Repeatedly waiting too long to use the toilet (such as being fearful of using the toilet away from home)

What Should I Know About My INFANT’S Diet If (S)He Is Constipated?

• Baby foods low in fiber and high in starches, which may worsen constipation, include: carrots, sweet potatoes, squash, bananas, applesauce, & rice cereal. You do not need to avoid these foods, but rather avoid pairing them at a meal. Balance these foods with foods that are high in fiber and low in starch (next).

• Baby foods high in fiber and low in starch, which may ease constipation, include: oatmeal cereal, barley cereal, apricots, prunes, peaches, green beans, and spinach.

• Infants without constipation should avoid fruit juices until at least 12 months of age. However, if instructed by your child’s physician or nurse, up to 4 ounces per day may be given to ease your child’s constipation. Juices containing sorbitol are best, such as apple juice, pear juice, & prune juice.

• Extra water is generally not needed in an infant’s diet. However, adding extra water (1-2 ounces, two or three times per day) might help to ease your infant’s constipation

• In some cases, constipation is caused by the infant formula. Some infants become constipated with dairy-based formulas, others with soy-based formulas. If you suspect formula is the cause of your infant’s constipation, talk with the doctor or nurse about a trial of alternate formula. A minimum of a ten-day trial is needed. The iron that is added to infant formulas does NOT cause constipation…please do not attempt a trial of iron-free formula.

What Should I Know About My OLDER CHILD’S Diet If (S)He is Constipated?

• Increase your child’s daily water intake to at least 2-3 cups (16-24 ounces) per day. Consider using sorbitol-containing fruit juices up to 4 ounces twice daily.

• Fruits and vegetables with every meal are a must! Raw fruits and vegetables are best if constipated, though steamed or broiled vegetables are also good. Examples include: prunes, raisins, figs, dates, peaches, pears, apples, apricots, beans (including refried), celery, cauliflower, broccoli, spinach, & dark salad greens. Keep bananas, potatoes, and applesauce to a minimum.

• Healthy whole grain foods are also important, ideally with every meal. Examples include: bran cereals, Original Cheerios, low-sugar oatmeal, cream of wheat, bran muffins, shredded wheat, low-sugar graham crackers, brown rice (never white), unbuttered popcorn, whole wheat pasta & whole wheat or rye bread.

• Avoid an over abundance of starchy foods, such as: white bread products, white rice, white pastas, & dairy products. Children older than 1 year only need 2-3 servings of dairy per day (the equivalent of 12-16 ounces of milk). Of course, a few starches are okay, so long as they are balanced with fruits, vegetables, and whole grains.

What Else Can I Do With My Older Child Who Is Constipated?

• If your child is actively toilet training, or trained, (s)he should be encouraged to spend unhurried time on the toilet after every meal, especially breakfast, in order to establish a regular bowel movement pattern. However, DO NOT FORCE a child to sit on the toilet. If (s)he refuses to stool except in a diaper or pull-up, it is okay to allow this.
• Develop a star chart to mark every successful bowel movement, and offer a reward for every 3 then 5 stars.
• Keep activities (books, magazines, colorforms, etc.) nearby the toilet to encourage unhurried time on the toilet.
• With infants, as well as toddlers and even some pre-school aged children, consider regularly lubricating the anal area with Vaseline to ease the transit of the stool and prevent tight clenching and withholding. The simplest way to lubricate is by the use of a rectal thermometer dipped in Vaseline and insert it until the silver tip disappears.

What If All This Fails?

• If a consistent change in diet and fluid intake fails to relieve your child’s constipation, the nurse or physician will likely recommend a method of disimpaction, to empty the rectum of its large amount of impacted stool. This may be done orally, with products such as Milk of Magnesia or MiraLax™ (generic: Glycolax), up to a maximum of 6 capfuls daily. Or disimpaction can be achieved rectally, with enemas and/or suppositories.

• If disimpaction proves successful (usually taking 3-7 days), it will be VERY IMPORTANT to begin a maintenance method for the next 3 to 9 months, to allow time for your child’s over-stretched rectum to return to its normal size. The BEST option is Polyethylene Glycol (MiraLax, Glycolax), which is odorless, tasteless, and NOT habit forming! It is best mixed in water or weak juice, and best given in the morning, though it can be given up to three times daily.

• For children who have ENCOPRESIS (accidental soiling due to severe chronic constipation), we also recommend chocolate ExLax at bedtime, and added fiber throughout the day. FiberOne bars make an excellent after-school snack.

• Do not use enemas or suppositories without the advice of your nurse or physician, as these methods could become habit-forming, or might cause rectal tears or fissures with overuse.

• In severe cases, a child may be hospitalized for disimpaction by way of an infusion of GoLytely, a safe polyethylene glycol solution which is unpalatable and therefore administered by nasogastric tube.

My Child’s Constipation Care Plan

□ Diet Adjustments: _____________________________________________________________________________

□ Fluid Adjustments: ____________________________________________________________________________

□ Disimpaction Method: _________________________________________________________________________

□ Maintenance Method: _________________________________________________________________________

□ Follow-Up Appointment: ______________________________________________________________________

□ Labs or Tests: ___________________________________________________________________________________