Constipation (preschool through middle school)

Constipation is very common for school age children.  It often presents as recurrent abdominal pain, usually close to the belly button, and often worse after meals, especially dinner.  Most kids who are constipated say they poop every day.  The problem is often they are only pooping small balls, and the whole system is backed up.  Parents usually assume that eating more fiber and drinking more fluids will help, and it might, but one of the main causes of constipation in school age kids is not pooping when their body tells them to poop.  They are very picky when it comes to toilets, and most will not poop at school, stores, movie theaters, etc.  It is very important to teach them to poop when their body says they need to.  When they don’t the stool gets drier and leads to constipation.  Often constipation presents in the office as “diarrhea”.  How is that possible you ask?  Good question!  They can get so constipated that their colon gets stretched out, which causes it to lose strength and sensation, so fresh, new poop will leak around the edges of old poop and eventually it will even leak out into their underwear.  Often teachers and parents think the child has control over this - they don’t.  It happens without them being aware of it, and they will even get so used to the smell of their own stool that they will not notice the smell either.  This is called “encopresis” which is really just chronic, bad, constipation.  All of this drama leads to stooling being a very negative experience for young kids, and what would an average young kid do if they know they don’t like something?  You guessed it - avoid it.  So they start holding in stool because they know how miserable stooling makes them feel.  Adults are completely different, in the same situation, we would use our adult logic to poop the second we notice we can, but kids don’t think like us.  

How can we help?  Miralax is truly a miracle laxative.  It has changed how we treat constipation and encopresis entirely.  The goal 1) to make the poop so urgent the child can’t decide to hold it until they get home to use their favorite toilet, and 2) to have them pooping so easily for 2-3 months that they stop being afraid of stooling and their colon has a chance to snap back into shape.  For most kids we start with 2 caps of adult miralax a day, with the goal of 1-4 loose soft happy stools per day.  Once they get very watery, we back it down to 1 cap a day for the next 2-3 months.  The biggest mistake families make is stopping the miralax too fast due to their child having a few days of normal poops.  The problem is their intestines haven’t snapped back into shape yet, so a few days later they are back where they started.  During the 3 months of miralax, sometimes the dose has to go up or down.  I use the rule of 2 for that.  If your child is on it and starts to get constipated again, double the dose.  If you are on 1 cap, go to 2 caps.  If a child is having watery stools and too many stools, instead of stopping the miralax, cut the dose in ½, so if you are on 1 cap then go down to ½ a cap a day.  This up and down by multiplying or dividing by 2 works very well.

School tip - I encourage all my patients on this regimen to put a pair of shorts and underwear in a ziploc bag in their backpack.  That way if they have an accident at school, they can quickly put the smelly clothes in the ziploc, and use the clean clothes.  Once the ziploc is zipped, smell will not be an issue.  Also, make sure the teacher knows what is going on, so that bathroom access is immediate.

There are websites that talk about the horrors of miralax, these are not credible in any way and I encourage you to avoid them; there is zero science behind anything the opinions on those sites.  Miralax is the safest medicine I use, and is so safe, that when we used to “clean out” kids in the hospital, we would use 24 caps of miralax over a 24 hour period in school age children.  The only side effect - diarrhea.