My difficult child 2 had severe constipation as a consequence of having Crohn's. Even when he's not flaring he has some degree of problem. I would take your difficult child to the doctor and make really sure there is nothing else going on since this was my difficult child's main symptom for a long time. It's highly unlikely to be anything more than typical constipation but it pays to go see his pediatrician about it when it hangs on like that. If the peds gives the all clear then this is my advice since we have been through every possible exam/test and treatment for severe constipation. This info is based on discussions with many different GI's and trial and error.
1. Dietary stuff -
Up his water intake as much as you reasonably can do. He needs to be sipping water through out the day.
Add to his diet:
apple juice (less intense than prune juice) or apricot nectar or pear juice
cherries, pears, apricots; can be cooked or raw
Avoid/reduce:
applesauce (constipating)
dairy products especially cheese
iron - if he's taking a multi with iron you could try one without iron for a little bit
foods high in oxylates like spinach - they have a lot of iron bound in them and normally are something you want them to eat
dried anything - fruits, etc.
diuretic substances like tea, coffee, soda's
2. Exercise is essential, as tolerated. Often when difficult child 2 is really constipated he will hurt if the exercise is too vigorous. So exercise as tolerated.
3. Laxatives -
It's best to combine laxatives with a toilet routine (next) for the reasons you have already discovered. Also, except for Miralax and fiber supplements like Benefiber, laxatives should never be used long term and if other kinds of laxatives are being used regularly it should be under a doctor's supervision.
Add Miralax as directed by your doctor or at least one dose a day. It can be mixed in almost anything liquid and is odorless and tasteless. It does make a very small change in the texture of liquids - makes them a little slippery. If you have a sensitive kid he may notice it - mine did. You may need to use the brand name stuff (mucho expensive) if the generics taste nasty. If your doctor prescribes this you may be able to get it covered by your health insurance.
Add Benefiber or another similar fiber supplement to counteract any tendency to have leakage or diarrhea from the miralax. It may take some trial and error to figure out the best balance between these. The miralax makes thing slippery so they go through easier and the fiber helps hold things together without interfering too much with the miralax.
An alternative when it's occasional constipation is mineral oil. But you have to use a lot (up to 1/3 cup) and it is nasty. If you are going to try it, the best technique is to get a large syringe and squirt it into the back of the throat followed by a chaser of lemonade. It will turn his poop bright orange so don't be surprised by that.
4. Toilet routine - essential step
They body's natural rhythm is to go about 20 to 30 minutes after eating. You need to have him sit on the toilet (even if nothing happens) for at least 10 minutes each time he has a meal so he is on the toilet during that time window. It's OK if he reads a book, has a special toy to play with while he sits that he only gets while sitting. a star chart - whatever works for him. Doing it consistently for several weeks may be needed to re-establish a normal pattern for him. And it will work if he sits for at least 10 minutes (15 - 20 would be better). It will also help him overcome the anxiety he has started to experience about this.
5. Treatment of fissures -
He's getting fissures or tears in the skin. These are, as you have said, very very painful. The tears are hard to heal up because the pain causes the sphincter muscle to spasm so the tear is getting pulled apart all the time even when he isn't actually going.
What will help the most is sitz baths - plain warm water for 10 minutes 2 or 3 times a day. One routine you could try is to have him eat, have him sit for 10 minutes and then have him take a warm bath for 10 minutes.
Also they need to be kept clean and he should apply a heavy cream/ointment after each bm. Aquaphor is the one our GI recommends but there are a number of equivalent things out there you can use.
6. Massage -
You can rub his belly as often as you like using a deep. firm touch. It should not be really painful but may be uncomfortable in which case you ease up some on the pressure. You want to rub in the direction the gut actually works. So you would start low on the left side, rub across the lower belly then up the right side. across the upper belly going from right to left and then down the left side. This will help stimulate the muscles to move things along.
7. Once severe constipation has become chronic it causes the gut to lose it's elasticity which then makes it even harder for the gut to do what it has to do. It can take up to a year for the gut to recover once chronic constipation has been relieved so you will need to look at this as a long term concern and keep up the miralax/benefiber combo for at least a year after he gets a regular pattern established.
I wouldn't try to be sneaky. It didn't work here and I doubt it would work with most 10 year olds. If possible involve him in this process since it is his body and he may have this problem the rest of his life and needs to develop appropriate skills now.
Good luck,
Patricia
he's actually sat on the toilet and screamed like he was giving birth...the whole house came running! It's just not right.
