CONSTIPATION IN CHILDREN

by Digestive Disorders Foundation

What is constipation?

Constipation is frequent and/or difficult passing of motions or stools (also known by different names, including faeces, 'big jobs', 'poo' or opening of the bowels).

What are stools?

After we swallow our food, it starts a long journey from the mouth to the anus (bottom). It goes through a lot of processes which allow us to absorb the good things while seperating out the things we do not need. As the food passes through the bowel (large intestine, large bowel or colon) water is absorbed and the stools, made up of waste products, are stored in the last part (the rectum). As the rectum fills, a message is normally sent to the brain as a warning that a loo will need to be found soon, so that the stool can be passed. Sometimes entry of the stool into the rectum gives rise to no sensation and this can lead to constipation.

Who suffers from constipation in childhood?

Constipation can happen at any age, among babies, toddlers and older children.

What are the causes?

There is a mixture of causes of constipation. The body needs a lot of fluid. When a child does not drink enough water or other drinks, or during minor illnesses like colds or flu which increase the body's need for water, the bowel tries to absorb as much fluid as possible from the stools. This can make them so dry and hard that they are difficult, or even painfull, to pass. The child may then put off going next time because he/she fears it will hurt. Delay makes the stool harder and harder.

Some parents and children are more sensitive to worries about stools than others. Parents can become worried about a child who is unable to go. A battle can develop between the worried mum or dad and the child, who expresses independence by not going. When the stools are not passed they become harder so that a genuine difficulty in passing them develops.

How does the child with constipation feel?

They feel irritable and out of sorts, and may have pain in the tummy (abdomen). When the constipation lasts along time, the rectum becomes very full and some loose stools may leak out. This stains clothes and can be embarrassing.

How can children avoid constipation?

During early years , a regular bowel rhythm is not yet established and children should be encouraged to pass a stool when they need to, Parents need not worry if there is apparently a gap of a day or two between stools. They should become concerned only if passing stools is painful for the child, or the child suffers from tummy pains, or stools leak onto the underclothes.

When should the child see the doctor?

Occasional difficulty in passing a stool is nothing to worry about. However, if bouts of constipation become frequent and last more than a few days, it is wise to see your family doctor. The doctor will be able to check if there is a serious amount of stool retained and advise about diet, medicines, other treatments, and the possible need for further investigation. When are investigations needed? In most cases, no investigation is needed. Such tests are only arranged when the condition is very troublesome and does not respond to treatment. An x-ray picture of the abdomen may be taken to see where the stools are and the width of the bowel. A special x-ray called a barium enema might be done. A small amount of liquid is put into the bottom and x-rays taken, which show up the shape of the lower bowel. A little balloon may be placed in your child's bottom, so that recordings can be made of the muscles squeezing and relaxing. A record is produced on a tracing which both doctor and patient can look at. When a disorder of the nerves supplying the lower bowel is suspected, a fragment of the bowel lining (a biopsy) may be taken for microscopic examination.

Some consultations aim to understand the background to the problem and involve talking over any worries that the child and the family may have.

What is the treatment

Food and drink - Foods containing fibre speed up the movements of the bowel and help to keep stools soft. Those containing lots of fibre include whole-wheat and bran containng breakfast cereals, porridge, wholemeal bread, wholemeal flour and bran used in cooking, root vegetables, fruit with skins like apples and pears, soft fruit, grapes, baked jacket potatoes (with the skins). It is important to have plenty to drink (6-8 cups every day).
Routine - For older children, it helps to establish a regular routine of going to the loo after breakfast so that the body gets used to a regular rhythm. Keep some comics by the loo. Leave plenty of time so there is no sense of rush. See that the loo is private and not too cold or unpleasant in any way.
Medicines - Some medicines provide roughage, such as methyl cellulose )Collogel, Celevac, Cellucon), bran tablets (Fybranta), Ispaghula (Regulan, Metamucil, Fybogel, Isogel), and Normacol. Medicines containing sugars which help to keep the stool soft include Duphalac and Lactitol.

If constipation goes on for a long time, laxatives can help. They make the stools move faster and the rectum squeeze more. Milk of Magnesia is a simple and harmless laxative in normal doses. Standardised senna (Senokot as syrup, granules, or tablets) is commonly used. Sometimes it is necessary to take a medicine, like Docusate, which softens up the stools, before taking Senokot. The doctor may suggest a combination of these medicines. If constipation has persisted for a long time, the doctors may need to clear the stools from the rectum using an enema or occasionally under an anaesthetic. This may be done as a day case or the doctor may advise a stay in hospital for a few days.
Muscle training - Some children contract rather than relax-as is normal-the muscles around the back passage when they go to the lavatory. Such children may be helped by special training (biofeedback).
Prevention of soiling - If a child is troubled by leakage of stool on to the underclothes, this is usually due to the fact that the rectum is full. Treatment aims to keep the rectum empty using regular laxatives, possibly combined with muscle training.
General - Sometimes social workers, child psychiatrists or other therapists may be able to help relieve some of the fears, worries and misunderstanding surrounding the whole subject of constipation. A short stay in hospital may help because parents and children meet other families with similar problems.
Surgery - A few children with abnormalities of the nerves (Hirschsprung's disease) or muscle (megacolon) of the bowel, need an operation to correct the constipation.

How much do we know about constipation?

The causes of constipation are not fully understood and we need to know why some children are troubled in this way, whereas most have no problem.