How to monitor and manage your child’s bowel habits and why this is important

This topic may not be very nice to talk about but I will do it in a very respectful and hopefully helpful way. You may also want to refer to the “What Causes Constipation?” YouTube video by Heba Shaheed posted on the website.

We like to use the Bristol Stool Type Scale for Children to help our patients as young as 3 or 4 years old tell us what their bowel movements look like. You can find many different versions of this on the internet and we have one on the website. I often recommend that the family put a copy of this on the inside door of a bathroom cabinet (out of view for visitors) so the child can double check themselves.

From the way the poop looks we can tell whether the waste has stayed too long inside the person. The longer it stays in the colon (large intestine) the drier and harder it becomes. Often I even talk to children about the colon as a drier and explain that it does not have an “off” button. Poop always starts out as type #7 liquid diarrhea stool at the beginning of the colon on the bottom right of the belly. And it is best if the poop has left the body before it gets harder than type #4.

This means that it is usually best for the child to have a bowel movement once a day. Therefore I encourage parents to ask their children after dinner if they have had a bowel movement. If not they should certainly try right then and take advantage of the natural reflex in the body to get rid of solid waste after eating a meal.

A second thing that is useful to monitor is how quickly food passes through the child. With most foods there is no way to tell. But corn on the cob, beets, spinach, blueberries, seeds like sesame or some food colored foods are wonderful tracer foods which will give you a good clue about how healthy your child’s bowel habits are. It is a very good sign if you see these foods in the toilet bowl within 24 hours of the child eating them. We call this the “bowel transit time”.

Writing down what the shape of the stool is every day for a month is a very useful exercise for people who suffer from constipation. It can help monitor how the therapy is working as well. Just write the number of the stool type on one of the 28 toilets on this picture. If the child did not poop for a day leave it blank. You can also note if the child took any medicine to help the problem.

Some signs that your child is constipated may be:

1. They begin wetting their pants again well after being fully potty trained.
2. They complain of stomach aches.
3. They do not have a bowel movement every day.
4. The stool is hard and painful to pass.
5. You see brown streaks in their underwear in the laundry even after you have carefully reviewed their wiping technique.
6. They lose appetite or may even vomit.

Simple things you can do to encourage better bowel habits in your child:

1. Increase fruits and vegetables and other high fiber foods in the diet. If an adult should take in at least 25 grams of fiber a day we recommend that constipated children taken in 10 grams plus the number of their age in years. My constipated 6 year old patient should take in 16 grams. A pear for example has 4 grams of fiber.
2. Decrease dairy products. Cheese and lots of milk are very binding and could make things harder for the child.
3. Hydrate well enough to have the urine output look like lemonade.
4. Try for a bowel movement after a meal.
5. Regular exercise.
6. Stool under the feet for good toileting position.
7. Pay attention to the bodily cues. If you feel the poop is trying to come out go to the bathroom right then and don’t put it off.

There are also many medicines that are used against constipation. Some stimulate the colon to move a bit faster and should not be taken on a regular basis. Others will keep more fluid in the stool for longer (the same thing fiber will do) and there are many types of fiber supplements in chewable or gummy type form.

There are also fiber substitutes (like Miralax, Benefiber, Metamucil and the like) which should be mixed with the right amount of clear liquid and then taken very quickly so the fluid can get pulled into the colon. I think of these medicines like a very wet beach towel, which I throw into my drier with all the other laundry. It will take that load a lot longer to dry, which is the goal in this case. Many children start on ½ capful (8.5 gram) into 4 ounces of clear liquid daily. If you monitor the Bristol stool type and the bowel transit time carefully you will know if you need to decrease the dose to ¼ capful into 2 ounces or increase it to ¾ capful into 6 ounces.

On the video version of this teaching sheet I go through an example:

Lastly, let’s look at an example diary for a 6-year-old patient. You see how she had type 1 or 2 stools every day and that in her case it took about 2 days for the Miralax to have the desired effect of making the stool softer. For many constipated children this takes quite a bit longer. Remember it normally takes about 24 hours for things to pass through, so you will not see the results of Miralax in a few hours either. Once the bowel movements were softer the family had her eat corn and she passed the transit time test because they saw it in her stool within 24 hours. Then she could reduce the dose of Miralax and continued charting the daily bowel movements. I would not be a bit surprised if her wetting improved as well.

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