When I tell people that I work with kids who are constipated, I almost always get the same response: "Oh yeah, I bet their diet is so bad!" These people mean well and I don't fault them for faithfully repeating the conventional wisdom. Until ten years ago, I was one of them! But it's time to start changing the conversation about diet and constipation.
Diet (in this context, a lack of fruits and vegetables and whole grains) certainly contributes to childhood constipation. In all sorts of complicated ways. But when we are talking chronic, moderate to severe constipation, a lack of fiber is rarely the only cause. When it comes to treatment, adding fruits and vegetables is almost never a complete solution. Here’s why:
Once you’ve ruled out all of the pathologies that can cause childhood constipation (Hirschsprung's, Celiac, Cystic Fibrosis, Chron’s, hypothyroidism, spina bifida, anatomical malformations, etc.), you still have a long list of potential causes that are not directly related to fiber consumption:
- Physiological changes due to holding: This is the big one. Toddlers learn quickly how to withhold stool, and it doesn’t take long for their bodies to adapt to this witholding.
- The colon and rectum stretch out to hold more stool, which makes them less effective at pushing stool through the system and out of the body. Also, if the rectum is stretched out and full of poop, after a little bit the child will lose the sensation of a bowel urge.
- The muscle fibers of the anal sphincter and pelvic floor shorten. You know how if you work your hamstrings a lot (like by running), they tighten up and you can’t bend down to touch your toes because the muscles just aren’t long enough anymore? The same goes for the muscles that tighten the anus. The muscle fibers shorten, and the anus is literally a smaller hole.
- Changes in the gut microbiome early in life. There’s still so much we don’t know about the gut microbiome, but kids with functional constipation are more likely to have been born via C-section, have had a short duration of breastfeeding, and have been treated with antibiotics in infancy. Scientists speculate these factors may negatively impact the microbiome, and make a kid predisposed to chronic constipation.
- Genetics: We know that functional constipation runs in families. I can’t tell you how many times I’ve treated a child, and after several sessions one of the parents says “this has helped me so much, too.” Also, genetics plays a part in a child’s gut microbiome.
- Sensitivity to certain foods: Milk consumption is linked to constipation in certain individuals. This isn’t to say that a child is allergic to milk or even lactose intolerant … just that dairy is constipating. If a child starts on cow’s milk around one year old, has some painful poops, and starts withholding, this child could be constipated no matter how many fruits and vegetables they eat.
To be clear, I could go on for days about how the standard American diet for toddlers is terrible. If I could change history, boxed mac-n-cheese and gold fish crackers would never have been invented. But constipation early in life is not only related to fiber consumption.
The solution for chronic constipation? Well, try to change diet, sure. I love talking food: my book has a chapter on how to make sustainable changes to diet that can help in the long term, and you will definitely find future blog posts with recipes for softer poops and a healthier microbiome.
But don’t expect changes to diet alone to fully resolve the issue. If the anus is shortened due to chronic withholding, it takes time for it to stretch out. If the rectum and colon are stretched out and full of old, hard stool, no amount of fruits and veggies is going to magically shrink that colon back. If a child no longer feels bowel urges, even the softest poop will get hard after sitting in the rectum for several days.
Bottom line (pun intended!): don’t feel bad about using medicine to treat constipation, and don’t feel guilty that your child’s diet isn’t perfect. When people tell you to just give your kids more fruit and vegetables, just smile and say you’re trying your best.
Until next time,
Christine
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