J’s Constipation

May 20, 2020

I'm a pediatric pelvic floor physical therapist, specializing in pediatric incontinence and constipation. Prior to J being born, so many people made comments about our child's future toileting abilities.

"You kiddo is going to be an amazing pooper."

Well, God had a lovely little chuckle in response to that. Lo and behold, at 6 months old, J is currently struggling with constipation. For clarity, I understand where it is coming from (he currently is taking a supplement recommended by his pediatrician which has a side effect of constipation). So, I was prepared for it. I was excited (and honestly a little taken aback) that the advice that I so often give to others, worked just as quickly and effectively for us!

Belly massage.

Colonic massage, the "ILU" technique, infant massage. Call it what you like, but it has worked for so many families that I have worked with, and now it is working for us. After starting a specific supplement, J went from having BMs 2-3x/day, to once every 2-4 days. J would struggle, his face would get red, and then he would have obvious relief.

Honestly, I panicked.

My mind immediately went down the road that I've seen so many families come to me from. Constipation in infancy, successful (though difficult) potty training, and then a resurgence of symptoms with constipation, incontinence, and abdominal pain, years after potty training.

But I reminded myself of what I would tell any other family in this situation, and I followed those steps and did the belly massage I would teach to one of my families struggling with this same problem. And less than 6 hours later, J pooped. Yay! Then I got complacent. I "fixed" the problem, right?! Wrong. After two more days without BMs, I panicked again. I did massage again. J pooped in less than 6 hours. Again. The supplement that J takes daily continues to cause constipation, so for the time being, his little (and very new) digestive system needs help combating the side effect of slower bowels. And since he takes this constipation-causing supplement daily, I'll continue to do abdominal massage daily, until I see him have a decreased need for it. But for now, when I skip a day of massage, his body skips a day of having a BM.

Not every baby needs to have a daily BM. It is all about context. J previously was having 3-4 BMs per day. After starting the supplement, he began going 3-4 days without BMs. He would get red in the face (and never had before) and would struggle through BMs with obvious relief afterwards.

With all of this in mind, 1 BM every 3-4 days for J was not enough. That's how I knew I needed to intervene.

How to do abdominal massage:

  1. Set up the environment. You need your child to be relaxed, lying flat (ideally with their hips and knees bent a bit), and they need to be agreeable to you pressing on their stomach. Distraction, singing, anything that will keep their stomach muscles relaxed. If you feel them pressing their abdomen out at you in response to your pressure, sustain contact, but back off and wait for them to relax.
  2. Know where you're going. Find the ribs and the hip bones (the landmark is technically the ASIS, or anterior superior iliac spine). These bony landmarks will guide you so though you likely won't be able to feel the large intestine, there is a great chance you're massaging it.
  3. Slow, slow, slow! Go slower than you think, moving your fingers in small clockwise circles, about the size of a quarter, taking about 1-2 seconds to complete that small circle. Make sure to keep your fingers (or thumbs) flat, with the most surface area of your fingers, rather than pointing your fingers down into the belly. When you point your fingertip into their belly, it is uncomfortable, and they will likely press their belly out at you to resist.
  4. Deeper than you think. You (about two thirds of the depth of their abdomen).
  5. Complete these small, quarter-sized circles in a larger, clockwise circle over the entire abdomen. Use the hip bones and ribs as your guide. Some circles can go wide, encircling the width of their whole abdomen, while some circles can be narrow, and barely go around the belly button.
  6. The goal is to feel (and sometimes hear) what I call "bubbles," or "gurgles." This is an excellent sign, that means peristalsis is happening, the large intestine are kicking into gear, and stool is moving. Success!
  7. Wait. With J, the effect of belly massage sometimes takes 30 minutes. Sometimes it takes 6 hours. Everybody is unique, and within that body, the stool location (and consistency), as well as other factors that influence the colon are unique. Which means no massage will have the same exact outcome, even if you do the massage at the same time, same place, same technique, etc.

Find the ribs, ASIS landmark

Find the ribs, the ASIS landmark, and visualize the "question mark." Begin at the left lower blue circle in the photo, moving up and across the belly at the level of the ribs, then down towards the right lower blue circle, and finishing out down towards the groin.

Notice the depth under the ribs

Notice the depth under the ribs. This depth is appropriate as long as they remain relaxed. It is inappropriate to press to this depth if they are pressing outwards with the abdominal muscles at all.

The lower right quadrant

The right lower quadrant (where my thumbs are) is about the location of the ileocecal valve. Spending some extra time here might help stool move easier from the small intestine into the large intestine.

In a child older than J, this left lower quadrant (where my thumbs are) is typically where you can feel harder stool in a constipated child.

In a child older than J, this left lower quadrant (where my thumbs are) is typically where you can feel harder stool in a constipated child.

After completing the question mark once, don't stop! Continue to repeat this pattern until one of the following happens:

  1. Your kiddo no longer is tolerating it,
  2. You hear a good amount of "bubbles" or "gurgles" happening, or
  3. You reach 5-10 minutes and neither of these things have happened. If you stop massage because of number 3, make an effort to try massage again that day.
  4. Have you ever tried abdominal massage before? If you have, is there something you could do to make the effort more efficient or effective? Have you tried music, singing, or other distraction techniques? Could you possibly try massage during nap or sleep time?

    Unconstipated Kids | Dr. Keller
    Dr. Keller hopes that through this site, conversation, and community, kids and their families can experience positive progress towards improved health. See the 'about me' section for more about Dr. Keller!