Soft Snakes in the Lake- All about Constipation

Constipation is an ugly thing for any of us- from babies to old folks. It can range from an annoyance to a serious medical problem, and should never be ignored or dismissed.

However, before you reach for over-the counter medications, parents need to think carefully about what is normal and how your child became constipated in the first place. Constipation is a common reason to see the pediatrician, so don’t be shy if you’re worried about your child’s pooping habits. The longer you wait to do something, the harder it will be to correct the situation.


So what is a normal, healthy bowel movement (BM) or poop? Broadly speaking BMs vary from loose and watery to hard and stone or pebble-like.  What we want is something that looks like a snake. Soft snakes in a lake (of toilet water)! If you describe it this way, your kids will know what you (and they) are aiming for.  Most parents tend to worry more about hard infant or toddler poop, but constipation sneaks up on many families with school-aged children. After children are toilet trained and wiping themselves (around age 4 or 5) many parents no longer have a look in the toilet bowl.


Any child can be constipated, but it is rare to find constipation in breast-fed babies. Constipation is not just hard poop but rather a combination of hard stools and not pooping every day.  The most common reason for constipation is the lack of fiber in a child’s diet. The stool stays in their colon longer than normal, which allows more water to be reabsorbed, making the stool even harder. Then it becomes painful to push it out and so there is a tendency to avoid the toilet and the discomfort that comes from passing hard stools. This is a feedback loop that tends to get worse and worse over weeks, months and years.

holding stools

  • For babies, constipation is hard, packed stools (pebbles) that come out less often than every other day. A little blood on the outside is not uncommon from straining and tearing their fragile skin inside the bowel. The first response is to add a bit of juice (1-2 oz pear or prune daily) to the diet. If the child is over six months, increase foods with high fiber (mango, pear, prune) & decrease constipating ones (rice, cereals, banana, carrot, potato).
  • In toddlers and preschoolers, constipation often occurs because of a diet that is low in fiber and water, combined anxiety and pain with pooping as children potty train. Some kids just start holding their poop in as they worry and/or learn to poop independently on the toilet. Constipation is defined as hard, painful or dry poops (logs/pebbles) that come less often than every 2 days. Aim for a daily soft stool by increasing fruits, fresh vegetables and whole grains to ensure you don’t start the viscous cycle.
  • For children over age 4, the diagnosis of constipation diagnosis involves two or more of the following symptoms;
    • At least one episode of fecal incontinence (leaking poop)
    • History of a child holding their poop in rather than going poop when they feel the need
    • History of painful or hard bowel movements
    • Presence of a large fecal mass in the rectum
    • History of large-diameter stools that may obstruct the toilet


Medications for Constipation in Children:

In my experience, by the time parents are regularly using over-the-counter laxatives and stool softeners, there is already a significant problem. Keep in mind that if a child has been constipated for months, it may take months to correct the problem. With constipation the muscles in the rectum and colon can stretch out, which reduces their ability to push out stool normally and can also lead recurring fecal incontinence. This can be very embarrassing and stressful for school-age children and their parents. Healthy diets, activity and bowel habits will have to be relearned before things can get better.

  • Stool softeners: Stool softeners are found as powders, suppositories such as glycerin, or liquids like lactulose, and polyethylene gylcol. Softeners work to add water and soften the poop.  It is very easy to become dependent on these medications and therefore fail to address the underlying problems.
  • Enemas: I recommend seeing a pediatrician before using an enema to ensure it’s the right thing to do. Often a child will need a quick rectal exam first to ensure normal muscle tone and a good reason for using an enema in the first place (hard ball of stool in the rectum).
  • Laxatives: Laxatives are stimulant medicines that irritate the intestines to push the stool through. Laxatives come in powders, capsules or even chocolate squares. As with stool softeners, it is easy to become dependent on laxatives and some of them are potentially dangerous is used too often or incorrectly. 


A better way

The right way to “soft snakes in the lake” includes adequate dietary fiber, plenty of water every day, frequent physical activity and encouraging proper toilet habits. Children should be encouraged to spend several minutes on the toilet a few minutes after finishing a meal. This will help them take advantage of the natural reflect to make a stool following a meal. If the parents do not promote such a habit, kids tend to ignore the urge to poop in favor of more exciting activities and distractions. Doing this repeatedly leads to constipation problems. Children should be able to press the floor or a stool firmly with their feet while pooping. This helps create the pressure needed to push out a BM. Likewise, teach your lids to blow a pinwheel or other toy on the potty. This will also help create the internal pressure that makes pooping easier.

Reasons to See Me Right Away

Constipation usually does not require urgent or emergency medical visits, but some abdominal symptoms do. Here they are;

  • Severe abdominal pain that causes your child to double over
  • Blood in vomit
  • Blood in stool. Sometimes constipation causes small amounts of red blood on toilet tissue, but any red or black blood inside the poop or blood in the toilet water requires an immediate doctor visit.
  • Dangerous dehydration. May include high fevers lasting many days, diarrhea, fast heart rate, dizziness, decreased skin turgor tone, dry mouth, decreased urine output, lack of tears, unusually deep breathing, lethargy and/or irritability.
  • Risk of a toxic ingestion causing stomach pain.

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