Straining / Withholding / Constipation?

KalamazooMom,
We have similar issues with DD1.

It may be purely a behavioral issue with your son but based on the "redness" I would first suspect that the BMs are firmer than you realize. From everything I've read the "straining" to go may actually be "retaining", probably from having had one too many painful movements. Not to be too graphic but when he finally goes is there way more than you would expect, even once you factor in that he hasn't gone for a number of days? Is it wider than you would expect for a toddler? If his BM is roughly the width of an adult's that would suggest that it wasn't loose enough or soft enough to pass comfortably, which would explain the redness.

What type of fiber are you using, soluble or insoluble? If my understanding is correct, soluble fiber (e.g.: oatmeal, Metamucil / psyllium husks) works by capturing moisture which makes the stool softer. Insoluble fiber works by adding "bulk" and making the stool looser (as long as there's enough moisture). So they should both help, but for different reasons. I began suspecting that the oatmeal, Metamucil "cookies", and psyllium husks (soluble fiber) were aggravating the problem. DD's BMs "looked" soft and seemed to "give" easily when squeezed through a diaper but upon closer examination they were relatively firm and somewhat "gelatinous". If you've ever put Metamucil or generic psyllium husks in a small amount of water you have a good picture of the "gel" effect they have.

So I did some research and found one article (can't remember where) that suggested that soluble fiber may be problematic (hard to paraphrase why except to say that it makes the stool too "slippery") and that insoluble fiber is better because --for lack of a better term-- it has "traction" and therefore the muscles can grab it and "push" it through. I also learned that even insoluble fiber can make the problem worse if there isn't enough water intake since the body will re-absorb the water from the digestive tract, drying up the BM. I have also read that ideally the moisture should be mixed in with the fiber. I did try a non-oatmeal hot cereal but DD wouldn't eat it so I'm trying to get her to drink the water with her cold breakfast cereal. Something she doesn't seem to want to do right now; maybe because her appetite and thirst are off right now due to a cold.

DD is tough because she won't eat fruits or veggies; she has been getting a lot of high fiber breakfast cereals (e.g.: GM's "Fiber One" and Kashi cereal) for a couple of weeks but I am hoping to see some improvement now that we've pretty much eliminated the soluble fiber. Again, she has a cold/flu with a minor temperature so she needs even more water but her thirst is off and she seems to be drinking a little less fluid than usual so it could be awhile before we see some improvement.

I'm not sure I completely buy the "slipperiness" issue with soluble fiber because in desperation we tried mineral oil and Milk of Magnesia (mineral oil is the main active ingredient) and it may have have helped a little. These substances work by coating the BM so it will pass more easily. That would seem to contradict the theory against soluble fiber. Of course the slight improvement could also be the Karo syrup we've been giving on the recommendation of her pediatrician. The sugar in Karo syrup is supposed to draw moisture into the BM.

So the best I can come up with is that she's not getting enough water, in which case any kind of fiber could make it worse. But that doesn't make any sense either because she seems to drink a lot and has a fair number of "pee diapers" a day including one or two "water logged" ones. Plus, they don't don't seem as yellow as you would expect if she wasn't getting enough water.

At the end of the day my instinct is that for some reason, perhaps unique to her system, she is having trouble with the soluble fiber. This is based mainly on my observation of the gelatinous, deceptively soft, consistency of her BMs.

Here is a partial list of soluble fiber sources, in case you think this might be your son's issue.

SOLUBLE FIBER SOURCES:
Barley, Brown rice Currants, Dried beans Figs, French bread, Fresh peas, Methylcellulose (Citrucel), Oat Bran, Oatmeal ,Pasta, Prunes, Psyllium husks (Metamucil), Raisins, Rice, Sourdough, bread, Soy, etc

Because of her decreased appetite I modified the "Rice Krispy Treat" recipe and substituted 2 cups of "Fiber One" cereal and 1 cup of Kashi's "Cheerio" type cereal. (for a total of 3 cups of cereal), I put it in a small rectangular sheet and cut into 16 squares. I guesstimate that each square has a little more than 4 grams of fiber, most of which is insoluble. She'll eat a little bit at a time but I don't know if she'll ever really love it even when her appetite returns.

Of course it wasn't until after she'd had a couple of bites I remembered that Marshmallow Fluff has dried egg whites in it. She has a history of dairy (eggs / milk) intolerance. The main symptom was tummy distress. She'd gotten a lot better so we had re-introduced dairy. However, I have read that constipation can sometimes be the only symptom of a food allergy (milk allergies in particular.) We have been cutting back on her dairy intake but it was my intention to virtually eliminate it. I'm hoping the amount of dried egg whites in Marshamllow fluff is minimal; but if the color is any indication it's not.

I'd appreciate any input from you --or anyone else-- about soluble versus insoluble fiber, food allergies, etc. I am especially interested in feedback on the food allergy issue since my husband really questions that theory and is understandably concerned about cutting back on the dairy / calcium unnecessarily. It doesn't help that the pediatrician hasn't heard of this before. All she can say is that food allergies usually cause vomiting, rashes, etc.

Having done some more research on the issue it seems fairly well established that "too much" milk can cause constipation but I have read at least one article that suggests that for the dairy intolerant even a small amount might do it. I think the theory is that it irritates the digestive system, possibly robbing it of moisture.

Has anyone else had a child with constipation they suspected was due to dairy/milk intolerance, or perhaps some other food intolerance? Was total elimination necessary? Did it help?

Anyways, sorry for the longwinded reply. I didn't mean to hijack this post. I hope some of these ramblings are helpful; and, again, I'd appreciate any feedback from you or anyone else.

~Cath

I haven't tried suppositories or anything like that. I hope it doesn't come to that. I am going to just try more fiber and fruits like prunes, apricots, pears etc. I also gave him some apple juice this a.m.

And unfortunately, he actually told me this a.m. that he was "gonna squeeze" to keep the poop in so it wouldn't hurt! I assured him that if he let the poop out it would hurt less next time, and keeping it in wasn't good for him. We also talked about eating and drinking things that would make it easier to poop.

I am hoping to nip this in the bud before it turns into a serious issue.

Needless to say we will not be working on potty training this week!

KalamazooMom,
Yes, we have used the glycerin suppositories but only after she hasn't gone for 2 or 3 days. And yes, they do work but one of my big motivating factors is trying to avoid ever having to give her one again. As a new Mom I can honestly say it is one of the most heartwrenching experiences I have had in the past 18 1/2 months. It's right up there with feeling responsible for the big scab on her scalp caused by vacuum extraction.

After using one to "clear the system" she will go once or twice over the next day or so and then the BMs turn to "marbles" and the cycle resumes. If your son's problem isn't as bad as DD's then you might be able to break the cycle with one or two well timed suppositories but you obviously need to aggressively treat the underlying cause. Not to be discouraging, but we've been at it on and off for one to two months now.

Regarding a potential dairy sensitivity/allergy, it sounds possible if not probable to me. I don't know what incidental ingredients are in ranch dressing but dairy is the most likely suspect because it is probably the main ingredient and it is highly allergenic. If you're wondering why you don't see that with other dairy foods it's probably because they don't touch his lips (at least not as much). If he is getting a lot of milk, cheese, etc. then I don't see any harm in cutting back &/or partially or completely substituting with alternatives. Depending upon the degree of sensitivity then that might be more than enough to resolve the problem. Assuming of course that the potential dairy allergy is a major contributing factor.

Regarding BM volume, after a couple of days you would expect at least some moisture loss so the volume would be somewhat less than you would expect. Regarding width, if you have the stomach for it the best way to find out is to "catch him in the act" (when you notice him straining / retaining). Put him on the changing table, open the diaper and "see what developes". While you are at it try lightly massaging his tummy, slightly to the left of his belly button, downwards, in a semi-circular motion. This could help move things along.

FWIW I've also heard that squatting can help. I haven't had any luck in getting DD to squat at the critical time. You might have better luck with that since your son is older.

As far as "consistency" there's only one way to know for sure and you don't need me to tell you what it is. If/when you reach that point you may need to challenge your perception of what "soft" is. My husband realized what was going on before I did and even after I checked things out more carefully he had to remind me about the redness, similar to what you described, and the BM width relative to the softness/firmness of the BM; again, keeping her size in mind. My first impression was that it had some "give" to it but it was gelatinous. It's hard to describe but it was kind of like Silly Putty which is actually pretty firm. (TMI??)

Rainbowbird,
Good point about the prune juice. DD doesn't like it much but we have some luck sneaking it in with water and other juice flavors (1/3 each). It's obviously better if you can get the child to drink it straight since they are getting more fiber with the fluid. If I remember correctly prune juice has two grams of fiber per serving. The pediatrician also recommended pear juice which has a negligible amount of fiber according to the label but you can tell from the texture it has a larger "trace" amount than the average juice. We have had better luck getting her to drink that straight.

Juice in general is probably good due to the high sugar content. That's why you aren't supposed to give it to sick babies since it can cause diarrhea. I think the pediatrician recommended the Karo syrup since it is more concentrated (although you are supposed to give it with water) and you can control the amount of sugar. We've had pretty good luck keeping DD off of straight fruit juice and I don't want this problem to undermine that. On the other hand, if I knew it would resolve the problem I'd give her nothing but fruit juice and deal with weaning her off of the fructose habit later.

Thanks for the Kiwi idea. Unfortunately DD does not eat veggies and fruits, especially tart fruits. She used to eat grapes if DH peeled them but now she just plays with them.

However, I had been thinking of breaking out the "Vitamix" juicer. Vitamix doesn't separate out the peel/pulp. If I make some juice, add some corn syrup and make some popsicles maybe she would eat those. The problem is counter space and freezer space but it could be worth the effort. If I wind up trying that I will try to remember to use Kiwis.

One more question for the both of you and anyone else that might be reading this. To your knowledge does Mineral Oil / Milk of Magnesia cause gas? It seems like it is causing her some tummy distress which probably makes sense. One of those pediatrician sites, possibly Dr. Sears, recommends flax seed oil as a nutritious alternative. I am wondering if it is more "digestible" and therefore might cause less of a problem. It wouldn't be a big deal except that sometimes it makes her uncomfortable enough that it disrupts her sleep (and mine if she doesn't sooth herself back to sleep).

That reminds me, ground flax seed is supposed to be a great fiber supplement for constipation. Generally you buy them unground and grind them yourself, using a pepper grinder or coffe mill. Keep in mind that both flax seed oil and flax seeds turn rancid very quickly unless you refrigerate the oil after it is opened and the seeds after they are ground. I'm having a hard time thinking of a food I can sneak ground flax seed into except perhaps hot breakfast cereal. Let me know if you have any suggestions.

If you are interested in trying flax seed oil &/or flax seeds you would need either need to go to a well stocked "whole food" store or a store that sells supplements like the Vitamin Shoppe or GNC.

Thanks for the input & Good Luck, ~Cath

I know what you mean about juice. DS doesn't usually get much, either. But I feel if it works, I'm gonna let him drink it and we'll wean off it later.

What about mixing the flax into yogurt? BTW, Stoneyfield Farm has 3 grams of fiber per serving, via inulin that is added.

You could also put the flax into pudding or mashed with banana? Or another fruit she likes?

If she'll drink smoothies you could blend a bunch of fruits with the flax and serve it with a straw, since smoothies often clog sippie cups.

Also, I just remembered that berries have tons of fiber.

We need to go to the store, I guess!

Although, DS has been having foods like grapes, carrots, etc. and still this problem. In fact he is in the corner now, trying to do his thing and telling me it hurts. He doesn't want to squat or sit on the potty. Just wants to be left alone so that is what I'm doing.

We're going for a walk in a bit so maybe if he doesn't poop now, the walk will get things moving!

I hate this! However, I';m trying not to get too stressed or emotionally involved since I know he'll pick up on it and probably get even more concerned.

Good luck!

Oops I meant soy or tufu pudding/yogurt if you're trying to avoid dairy.

Our little guy went through this phase. It is now over, I hope.

What helped:
1) a visit to the family doctor. She suggested coalace. It has been a miracle pill! For a few weeks we gave coalace every 3 days. Other over-the-counter meds or Karo syrup were not this effective.
2) We have a "prize box" We gave stickers and prizes for BM in diaper.
3) Increased fruits in diet drastically... grapes, watermellon, etc. NO banannas!

The Dr suggested that 1) is a control thing, he wants to control it. 2) after a single bad experience, a toddler does not want to ever make a BM again. THey don't understand that this is not an option!

Now, everything is "back to normal"

Rainbowbird,
Thanks for the suggestions. FYI, bananas are binding. If you mashed them with something like flax seed the fiber might offset the binding effect of that one banana somewhat but it won't solve the overall problem. Other binding foods are highly refined carbohydrates ("junky"/empty carbs) such as white bread, low fiber cereals, cookies, crackers, white rice, etc; and starchy "root" vegetables like potatoes and carrots. My understanding is they basically turn to paste in the digestive system.

One of my big pet peeves with DH is that it seemed he was frequently handing her a cookie or cracker even when she wasn't looking for something to eat. Come to find out that he was concerned about her "fat reserves" in the event that she got really sick. She is in the 90th percentile or so for height and 50th percentile or so for weight but she has an appropriate toddler "pooch", dimpled knuckles and the indented line around her wrist. We discussed this at DD's last doctor appointment and the pediatrician told him that she is not underweight and that her fat reserve is appropriate for her body type. I was having a hard time understanding why he would risk setting her up for an obesity problem later in life on the mere possibility that she might become sick enough that a fat store would be important.

However, he has gotten a lot better about giving her fewer cookies and crackers and substituting high fiber cereals when she is looking for something to eat. But there is still room for improvement. In our quest for high fiber snacks we hit a local whole foods store and he picked up organic animal crackers and ginger snaps. They both have the same amount of fiber as a serving of regular cookies,
< 1g, but he is convinced the animal crackers in particular have more fiber since they have a gritty texture.

Incidentally, she hasn't had a yeast infection in months now, which probably has a lot to do with cutting back on the junky carbs, which lowers blood sugar. This is another reason I was trying to limit the amount of undiluted fruit juice she was getting. Of course, he won't concede this is the reason she hasn't had a yeast rash in awhile. Sorry, I didn't mean for this to turn into a vent. I should just give him credit for making the effort. And, in fairness, he identified the constipation issue long before I did.

Regarding soy, a significant percentage of children with dairy allergies are also allergic to soy so I tend to avoid obvious sources of soy. I'm not obsessive about avoiding "hidden" soy but then again I don't scrutinize ingredient labels for hidden dairy either. Hidden dairy can be harder to spot since the word milk is usually missing (e.g.: casein, whey, etc.).

SleeplessMommy,
How old is your DS? How long has it been since you gave him the Colace?

DD's pediatrician might have mentioned Colace but my impression at the time was that it is a "stimulant", which supposedly could cause dependency. I just checked though and it isn't a stimulant. And the fact that you only had to do it for 3 weeks or so is pretty persuasive. I guess my only concern is that we may wind up masking the real issues: e.g. dairy intolerance and a diet that probably had to many "junky carbs" up until now.

It doesn't look like there is a liquid infant version. They do have dosage info for 2 to 12 year olds: Children 2 to under 12 years of age: 1 to 3 50mg capsules daily. (The adult capsules are 100mg). However, for "Children under 2 years: Ask a doctor".

So, obviously I would need to double check with the pediatrician for her recommendation and dosage info. However, the 1 capsule (presumably 50mg) you were giving every 3 days sounds fairly conservative. As a practical matter how do you get a 1 1/2 year old to take a capsule?

Thanks for the feedback everyone. This has been really helpful and informative.
~Cath

Just wanted to add my 2 cents

We had horrible, horrible constipation/witholding issues with dd, which lasted for over a year. Tried nearly everything, including glycerin suppositories, magnesium supplements, fiber supplements, etc. What finally worked for us was basically cutting out most grain, dairy, and meat products (no more crackers of any kinds, very little bread). So we mainly eat fruits, veggies, beans, and nuts. This involved our whole family changing our diet. Not that we ate horribly before, but we enjoyed milk and cheese, etc. Pretty drastic dietary change, but we were desperate for a solution.
The other thing we did was to emphasize that it was important to "go poo poo" every day. We talked about it quite a bit. Reminded her each morning that in the evening we would sit on the potty and try to go.

Within a month our year-long problem was solved. Now when we sit down to a meal, dd will often ask about a certain food, "will this help my poo poo?" Kind of a funny dinner topic, but I'm glad that she's realizing how the system works.
I know what a difficult problem this is. Hope you find your solution!

Quote:
No, no, Mama! No mama guilt here. I really don't think that your irritation would cause him to withhold. One incident like that wouldn't cause an ongoing problem in a normal, healthy toddler. So don't beat yourself up.

Did you try prune juice yet?

Quote:
Raninbowbird, thanks very much for your kind words of reassurance. I'll try not to go off the deep end with guilt here.

No we haven't tried prune juice. I'm going to get some today. Another friend also told me to try a spoonful of raw honey.

My MIL was here this week and she gave him lots of yogurt since he really likes it. I think that's part of the problem we're having at the moment. We're really starting to limit the dairy again now that she's gone.