A bowel management program for your child should begin when they're an infant to prevent constipation and keep their colon from becoming stretched, out of shape, and the sphincter muscles working properly.
The following sections provide information about a bowel management program for each stage in your child's life:
- Bowel management during infancy
- Bowel management for toddlers
- Bowel management for children five and older
Bowel management during infancy
During infancy, the goals of a bowel program are to maintain normal stool consistency (soft and easy to push) and to have an average number of stools per day. Routine emptying of the bowel and prevention of constipation will help keep the colon from becoming stretched out of shape and will help to keep the sphincter muscles working properly.
There is a wide variation in stool patterns in infants. Breast fed infants initially have as many as six to twelve stools a day, later one to six stools a day. Formula fed infants initially may have one to eight stools a day, but by six to twelve months they generally have one to three stools a day. Constant smearing of stool on the diaper as well as hard ball shaped stool may be the first signs of constipation.
The role of diet in bowel management
When you introduce solid foods or change from breast milk to formula, you will notice changes in your child's stools. You can prevent or treat constipation in infants by:
- Being sure your infant is getting plenty of fluids such as water and fruit juices. Offer prune juice, one to two ounces per day, straight or diluted with an equal amount of water or apple juice.
- Offering high fiber foods that are natural stool softeners as you introduce solid foods. For the infant, use oatmeal or barley baby cereals (not rice). Offer wheat grain breads rather than white bread.
- Offering most pureed fruits (not bananas) such as pureed prunes, 1/2 to 1 jar daily.
- Offering Fruit-Eze: A fruit paste made of raisins, dates, prunes and prune juice that provides a highly concentrated source of fiber. It can be eaten alone, added to cereal or yogurt, or as a spread on bread or toast. Store in the refrigerator. Use 1 teaspoon a day and adjust as needed. The company will provide information and samples. You can get these samples by calling: (800) 743-1941
- Offering Homemade Fruit and Fiber Spread. It is similar to Fruit-Eze but the consistency is not as smooth. Blend the following in a blender for two minutes:
- 1/3 cup raisins
- 6 prunes
- 1/2 orange (peeled)
- 1/2 unpeeled apple
- 2 TBSP prune juice
- 2 TBSP orange juice
Store in the refrigerator. Use 1 teaspoon a day and adjust as needed.
If your baby does develop small, hard stools or does not have a daily bowel movement, you may need to give a stool softening agent such as Maltsupex or psyllium powder. If your baby goes two days without a bowel movement, call your health care provider for suggestions about treatment.
Bowel management for toddlers
During the toddler period (18-36 months), it is important to continue to have good stool consistency, have a stool at least every other day and introduce the concept of regular toileting to the child. Stools should be soft and formed (log shaped) by about 18 months of age.
The role of diet and toddler eating habits
To get the right stool consistency, continue to give your child high fiber foods, like fruits and vegetables, wheat bread and high fiber cereals. During the toddler period, it is normal for children to be "picky" eaters. Since your child will develop his or her likes from what you offer, teach your child to like healthy foods now by offering good choices. Here are some suggestions that may help.
- If your child does not like a food, give small portions and praise your child for trying one or two bites.
- Give your child lots of water and juices.
- Limit milk to 16 ounces of low fat milk and limit other dairy products if they are constipating.
- Offer fresh fruits for desserts and snacks.
- At this age, special recipes such as psyllium jello squares or psyllium jello jigglers may be a fun way to provide fiber to the diet.
- If diet alone does not keep your child's stool soft enough, Fruit-Eze, a commercial high fiber fruit paste, made of raisins, dates, prunes and prune juice may be helpful. It can be eaten alone, added to cereal or yogurt, or used as a spread on bread or toast. Store in the refrigerator. Use 1 teaspoon a day and adjust as needed. You can get samples by calling: (800) 243-1941.
The toddler should have a bowel movement at least every two days. If your toddler does not have a bowel movement, contact your health care provider for suggestions on how to treat this.
Since children at this age learn by imitation, it is important to begin to expose the toddler to other family member's toileting habits. This means as parents, you need to bring your child to the bathroom so the child learns other family members have bowel movements in the toilet on a daily basis. This is especially important for the child who is not walking and unaware of others toileting habits.
Establishing a regular toileting time should be started. Observe your child to see if he or she gives signs, such as straining, to let you know when he or she is about to have a bowel movement. Keep a record of when your child has bowel movements and note if there is a pattern to it, such as after meals. Some children initially may need to use oral medication, such as Senokot or a suppository to help train the bowel to empty at a scheduled time. Your health care provider will make recommendations if these are needed.
As the child shows interest, you may begin to introduce your child to the potty chair. As with all children, there is a wide variation of age as to when the child is ready for this. Generally, around age three is a good time to begin to encourage the child to sit on the potty, but do not force it. This is called scheduled toileting or habit training.
A few training tips
- Have the child sit on the potty in the bathroom for a few minutes.
- Choose a time when your child is likely to have a bowel movement, such as after dinner or any time you might predict he or she will have a bowel movement. Have your child sit on the potty the same time each day. Consistency is very important.
- Choose a comfortable, well supported potty chair that rests on the floor. The child's feet should be flat on the floor or on a stool with the knees higher than the buttocks, so the child can push.
- Help the child learn to push (bear down) by coughing, blowing a piece of paper off your hand, or blowing a pinwheel.
- Make the time on the potty pleasant. Look at books, blow bubbles.
- Slowly increase the amount of time spent sitting on the potty to ten minutes.
- The initial goal is to get the child to sit on the potty. It is important to be positive and praise your child for sitting on the potty. Simple rewards such as a sticker may also be used. If the child does not have a bowel movement, encourage him or her to try again the next time.
- As your child develops a regular toileting time, he or she may begin to see some accident free days. It is especially important to work on developing this habit before your child begins school.
Weaning your child off the suppository
You may try weaning your child off the suppository once he or she is having regular bowel movements in the toilet. This is done by using the suppository every other day but still having your child sit on the toilet every day at the same time and encouraging your child to push. Continue to praise your child for having a bowel movement without the suppository. As the child becomes more successful, extend the toileting days without the use of the suppository. If you are using dietary fiber supplements or a stool softener, continue to use them.
If your child becomes constipated or goes more than two days without a soft log shaped stool, an enema may be given. The most commonly used enemas are pediatric Fleets enemas or homemade saline enemas made by adding one teaspoon of salt to one pint of water.
If severe constipation occurs, contact your health care provider.
Bowel management for children five and older
As your child approaches school age, achieving continence becomes very important for social reasons. If a child does not have a well established bowel program by this time, the child and parents must realize it may take several months to get a program working. It is important to keep providing your child positive support.
Goals at this age
- Develop good stool consistency and prevent constipation
- Establish a regular time for bowel movements to occur
- Achieve accident free days
- Achieve increased independence in self care
If your child has not been on a bowel program before or has not been successful with previous efforts at bowel training, it is helpful to obtain a two to three week record of bowel patterns. This record should include the number of accidents, when they occur, the consistency of stools, and degree of constipation. This information will help determine what type of program might be most successful with your child.
Before starting any program, it is important that the bowel be cleaned out. Your health care provider will recommend a clean out regimen. If your child has had chronic constipation, it may take several months for the colon to return to its normal shape. If a good stool consistency has not been obtained, a high fiber diet, adequate fluids and the use of a bulking agent (such as Benefiber or Miralax) should be introduced.
Children who are not constipated and have 2 or less stools per day are often successful with a habit training program. The habit training program is a program in which the bowel is trained to empty at the same time each day. This is done by having the child sit on the toilet and push at the same time each day. After a meal is often a good time since the child can take advantage of the natural elimination reflex that occurs after eating. Some children may need to use a suppository or an oral medication such as Senokot to help train the bowel to empty at a scheduled time.
Children with frequent (3 or more stools per day) or hard, ball-shaped stools may be more successful with an "enema continence program". This consists of administering an enema on a daily basis, at the same time each day.
Once an enema continence program is implemented and successful for several months, you may try to wean your child off the enemas. Do this by reducing the enemas to every other day rather than daily and begin habit training on the alternate days. The goal is to use fewer enemas as the child increases the number of bowel movements on the toilet with pushing.
In children with very lax sphincter muscles who are unable to retain a regular enema, a special enema tube called the Enema Continence Catheter may be used. This enema is used as a daily cleansing program to achieve continence. The catheter is a tube with a balloon at the end that can be inflated in the rectum. This allows fluid to remain in the colon. This procedure is done on the toilet.
If this fails, there is a surgery called the Malone or ACE (Antegrade Continence Enema). This surgery creates a channel to the bowel that can be catheterized. This channel will be used to give enemas, which will produce a predictable bowel movement.
Please keep in mind, no one bowel program works for all children. Each child needs to have a program modified to his or her needs. Through modifications, "fine-tuning," and consistent praise, your child can be successful.
Page reviewed on: Apr 29, 2009
Page reviewed by: Leslie T. McQuiston, MD