Grant MacDougall MD, FRCPC
Community Paediatrics Section Head
Department of Paediatrics and Child Health
No conflicts of interest to disclose.
Infant Dyschezia
 “My four month old baby hasn’t had a BM for a week!”
 Healthy breast- fed infants don’t generally become
constipated
 It’s normal for infants to strain before stooling
Introduction of Solid Foods
 8 month old Declan is starting to have hard BMs
 His diet history needs to be reviewed
 Try less rice cereal and increase barley and multigrain
cereals
 Other foods that are high in fiber include peas and
sweet potatos
 Add some water in a separate bottle if formula fed
 Don’t forget the prunes!
Cow’s Milk Introduction
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13 month old Owen likes his bottle
Tell his parents to stop that bottle
Limit the milk to less than 20 oz/ day
Avoid cheese and increase his fiber
Juices with sorbitol can help - apple,
pear, prune
Toilet- training issues
 Withholding – “I could poop in that potty, but I doubt
you can make me”
 “ Hey, that hurt- I just won’t poop ever again!”
Time for Advice:
 It’s difficult to toilet-train a constipated child
 Parents should back off for a while
 Again – increase that fiber- a 3 year might like beans,
lentils, and Bran Buds for a snack
 Use a foot stool if the child is on the toilet
Parent Concerns
 “How do you know the bowel is normal?”
 Review growth – consider celiac disease
 Look for abdominal masses, severe distension-
consider Hirshsprung’s
 Examine the spine, DTR’s, anal tone, lower limb
strength- tethered cord
 Anterior anus?
 Digital exam
More Concerns
• “ I don’t know about laxatives- I’ve heard they’re
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addictive”
Reassure
Consider: Lactulose 1-3 cc/kg/day bid – max 60 cc/day
Mineral oil (Lansoyl gel) 1-3 cc/kg/day od-bid- max 45
cc/day
Treat for long enough
Arrange for follow-up
Encopresis
 10 year Brandon is now soiling his pants at school, and
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the other kids are calling him names
Mom and Dad are losing patience with him
He has no interest in having a BM at school- “Forget
about it!”
His parents don’t know much about his stooling
pattern, and neither does he
He has been having abdominal cramps for months
Education
 Parents have to keep it positive
 Brandon needs to sit 2-3 x/ day for 5-10 min each time
 He should sit on the toilet after meals
 He should be rewarded for sitting/ not for success
 Parents have to understand that when the rectum is
distended with fecal impaction, there is a loss of
sensation and control
Treatment
 Brandon needs to be cleaned out
 The parents need to brace themselves- a large amount
of stool will come out of that child
 Treat with Polyethylene Glycol – Miralax, Restoralax,
Laxaday
 Clean out dose: 1-1.5 gm/kg/day – max 8 0z(17 gm) tid
 Maintenance: 0.4- 0.8 gm/kg/day bid
Follow-up
 Monthly return appointments at first
 Treatment will usually take at least several months
 Parents must be warned about not stopping the peg
3350 too soon
 Abdominal Xray is not needed in most cases, unless
the parents need to be convinced that their child is
constipated in the first place
Remember- The goal is a happy BM