Dear Dr. Johnson: My 3-year-old daughter has been having hard golf ball-sized stools. Should I be concerned, and what can I do?
Dear Reader: Stooling patterns between individuals can definitely vary, but hard, dry, painful or difficult-to-pass stools are an indication of constipation.
Constipation is a very common problem that most people must deal with at some point in their life. Usually, it is temporary and self-resolves, but it can also be more persistent and require treatment.
Constipation is one of the most common causes of belly pain in small children. While babies can have constipation, it is less common in this age group, especially in exclusively breastfed babies.
For babies, the consistency of the stool is more important than the frequency. For babies who are having hard, thick or pellet stools, it is best to talk with their doctor about possible causes and treatments.
Constipation is much more common in older children. There are various causes, and one of the most common is diet. Lack of fiber and fluids can increase constipation. An illness with a change in appetite can cause constipation. It also can be a side effect of some medications.
In addition, constipation can be a result of a child holding their stool. They do this for various reasons. They may be too busy playing to take time to go to the bathroom. They may not feel comfortable stooling at school or in public restrooms. They may have had a hard stool that hurt to pass, so they don’t want to go again for fear it will hurt again.
When they hold the stool, more water is absorbed from it into the intestine and the stool becomes harder, making the constipation worse.
Abdominal pain is one complication of constipation. In some cases, this can be severe. It is usually the worst after a child eats. The pain is felt across the whole abdomen and improves after a relatively short period of time (five to 30 minutes) only to recur later.
Pain related to constipation is caused by the intestine contracting in an effort to push the stool out but causing discomfort when pushing against the hard stool. The pain often improves when a child does stool.
Rectal bleeding with blood on the outside of the stool or on the toilet paper after wiping can occur when the hard stool causes tears in the rectum called fissures.
Over time, the rectum can become so distended from large stools that the child may no longer feel the urge to stool until the stool is too large to pass. There can then be leakage of liquid stool (accidents) around this big stool. This is called encoporesis.
One of the best treatments for mild or intermittent constipation is to increase foods in the diet with fiber and increase the amount of water intake each day. This is one instance that I also might recommend drinking fruit juice. The sugar in the juice can help pull water into the stool and soften it.
Encouraging your child to take regular bathroom breaks (especially after meals) throughout the day also can help promote a regular stooling pattern.
For children who don’t respond to increased fiber and water or who have more severe constipation, a medication to soften the stool is often recommended. Sometimes we also need to use a medication to stimulate the body to push the stool out (laxative), rectal suppository or an enema, depending on the symptoms and severity. These should not be used without first discussing it with your child’s doctor.
If your child has constipation that is not resolved with increased fiber and water or has abdominal pain or significant constipation, I recommend checking with her doctor to determine the best treatment.
This column provides general health information and is not specific advice intended for any particular individual(s). It is not a professional medical opinion or a diagnosis. Always consult your personal health care provider about your concerns. No ongoing relationship of any sort (including but not limited to any form of professional relationship) is implied or offered by Dr. Johnson to people submitting questions.