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Children's Health

Odd & Large Bowel Movement in 2 year old girl

11/20/2009

Question:

My 2 year old daughter has been having bowel movement issues for about 3 months now. Her movements are very painful: she pulls her legs up, curls up and cries. The stool starts out being "packed" "balls" in shape but once a dozen or so "balls" are passed, then a normal but large stool comes out. The overall diameter for both the "balls" and non-circular stool is just over 1". Her diet is still baby food with people food (mostly starches) afterward. She only drinks milk, typically 2%, at night and doesn`t drink anything other than water. There`s very little to no blood with each movement and she typically has one a day, rarely going two days without a b.m. We`ve been told she`s dehydrated but she has wet diapers about 3-4 times a day. Is there any way to help reduce the size which will make it easier for her to pass her stool?

Answer:

I am sure this is a miserable problem for your daughter as well as for you. None of us like to see our child in distress.

That said, what you are saying about her diet, stooling and wetting patterns indicates that she has several problem areas that need improvement. Let's take one of the easiest. She is not getting enough fluids during the day. She really should have 5 or more wet diapers per day. Water is the recommended alternative beverage to low fat or fat free milk. She may also have 4-6 ounces of 100% juice each day, which does contribute to a better stooling pattern as well as vitamin and mineral intake, depending on which fruit juice she drinks. be sure to offer her something to drink with meals and snacks, but it is best to offer the solid food first and then follow with a beverage so that she does not fill up on fluids and then not eat.

She may not be getting enough milk either, although perhaps she eats cheese and yogurt that help to make up the deficit in calcium. Children her age need two servings of dairy products each day to meet their calcium intake requirements for the day.

The most concerning nutrition issue is that she is still on baby foods at 2 years of age. Pediatric practitioners of all types support moving children to family meals and foods at 12 months of age. Of course, the meat and fish products need to be tender and cut into small, bite-size pieces. Raw, hard foods such as often found in salads also should be avoided because they are choking hazards for new table food eaters. Young children only have 20 teeth compared to our 32 and do not chew as well as we do.

Many toddlers choose food battles as a way to declare their independence from parents and to begin to define themselves as separate individuals. That may be what is happening here. Another possibility is that she has a great sensitivity to changes in the texture and thickness of foods - usually in the direction of preferring smooth as opposed to crunchy or chewy foods, and towards thin rather than thick. Another more distant possibility is that she is autistic. These children have tremendous difficulties with dietary changes, indeed any changes in routine, and often have bowel problems with either constipation or diarrhea or some of each. 

There are a number of pediatric professionals who can help with her eating problems. She needs a nutritionist or clinical dietitian to assess her food and fluid intake in detail and recommend changes based on this information. She may need a pediatric occupational therapist or physical therapist to help her work on accepting a variety of textures of foods and a variety of thicknesses. A behavioral pediatrician may also prove helpful in working with you to avoid falling into the trap of food battles, if this is a part of the problem. Dietz and Birch have a new book out, entitled Eating Habits of the Young Child.  It may prove helpful as well as Child of Mine by Ellyn Satter. Ellyn Satter also has a website that may be useful to you.

In terms of the bowel movement problems, she does have an element of constipation since she has dry, hard, difficult to pass stool. This is caused by inadequate fluid intake, infrequent stooling so that water is absorbed from the stool over several days as it sits in the large intestine, inadequate fiber intake (this is true for many children in the US), and/or poor motility in her intestines as whole so that food does not move along at a normal pace resulting in the stool becoming dry. Even though she has a bowel movement every day, she may function better with two per day to prevent drying of the stool.

These problems are seldom solved quickly. You have many fronts on which to improve her diet and fluid intake. these improvements, in turn, may solve the stooling problems by making the stool moister from better fluid intake and increasing her intake of fiber by improving her intake of fruits, vegetables, and whole grain foods.

Physical activity also stimulates the bowel to be more active. So if she is not already an active girl playing hard at least 1 hour in several 10 minute bouts throughout the day every day, work on getting her to the park more often, riding her tricycle, or walking with you or engaging in brief sprinting challenges, etc. Keep her TV and video viewing time to 1 hour maximum each day.  

If improvements in nutrition, fluid intake, and activity do not solve the problem, talk with her doctor about a fiber supplement daily. If that along with all of the other changes does not work, then a referral to a pediatric gastroenterologist would be in order to see if GI tract motility (movement) is the problem or something else entirely.

Your daughter's doctor can refer you for the help on nutrition and feeding. These services are available at most all children's hospitals. All of your child's diet and stooling problems are very common among toddlers. You are in the company of many other good parents and there are professionals who know how to help.

The best of luck as you tackle these challenging problems!

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Response by:

Mary M Gottesman, PhD, RN, CPNP, FAAN Mary M Gottesman, PhD, RN, CPNP, FAAN
Professor of Clinical Nursing
College of Nursing
The Ohio State University