Constipation

Constipation means painful, infrequent, hard bowel actions. This is a common complaint during childhood, and the right advice will avoid long term problems such as a soiling condition called encopresis. Medical causes of constipation are rare (<5%) but need to be considered in infants under 2 months of age, or children resistant to treatment. This guide helps demystify constipation, and educate parents on management.  

Introductionshutterstock_113785489

The frequency of bowel actions is highly variable in children. Some have several bowel movements daily, while others go once every several days. Infants have a average of 4 stools per day during the first week. After this they will generally lessen and some healthy infants pass a bowel action once every few days. As long as this is not painful and hard this is still considered normal.  By 2 years average is 1 -2 stools per day but again this is variable.

Definitions

  • Some infants struggle with normal soft bowel actions. This is called dychezia. There is no need for treatment.
  • Constipation means the passage of painful hard bowel actions
  • Chronic Constipation means this has occurred for 3 months or more
  • Anal Fissures are small tears in the anus from passing hard bowel action. These will be particularly painful
  • Encopresis means the child involuntary passes faeces into inappropriate places such as underwear, on a repeated basis once they are over 4 years of age. This is a result of untreated long term constipation in the vast majority of cases.

Background – Normal Large Intestine Function

The small intestine is responsible for transferring nutritional components to the body. Once this has occurred what remains moves to the large intestine and looks like ‘soup’. This soup includes waste products, fibre, bacteria, bile salts, and unused gastrointestinal secretions and enzymes. Much of this is water, and as it moves along  this is reabsorbed to produce the ‘soft sausages’ near the rectum.

The factors that are important in normal bowel function include the ‘personality’ of the bowel, the time it takes to get from one end to the other, diet and finally how often it is emptied. If one or more of these factors are sub optimal, then large intestinal function is affected.

How does constipation occur ?

It can be as simple as a painful bowel action. This experience can be so distressing, that there is a reluctance to ever open the bowels again. The trigger may be a temporary change in diet, an illness, or period of ‘withholding’. Young children, fearing another painful experience, will voluntarily stop an impending bowel action. When these children get the urge to defecate, they may stiffen their bodies, cross their legs, tighten their gluteal muscles, walk on tiptoes, or hold on to furniture.  Some squat or hide in certain areas of the house. Such behaviour often is misinterpreted by parents as an effort to push and pass stool. This is actually withholding behaviour and results in the ‘constipation dance’.

Managing constipation throughout childhood

Constipation in all age groups should follow the following principles. Early and aggressive use of laxatives to soften the stools, and then slow weaning is the ideal management.  Diet and increasing fluids are important in the long term but have little role in immediate management.

  1. Removing exacerbating factors
  2. Adequate age appropriate stool softening agents (laxatives)
  3. Improving toileting behaviour
  4. Healthy diet

Laxatives

Laxatives are given to help empty the large intestine. The most effective are called osmotic laxatives. This means all they do is attract water, which softens the stool. The first two are osmotic laxatives.

  1. Macrogol 350 – called  osmolax or movicol. It comes in a powder, which is mixed with water and can then be flavoured. It can be used from 12 months but is more commonly used in older toddlers and children
  2. Lactulose – Called Actilax – This is a dissacharide sugar that is safe in infants.
  3. Coloxyl drops – Used in mild cases, but not as effective
  4. Parachoc – Not as effective the first two. Side effects are oily discharge and not recommended in infants or children who have reflux due to risk of aspiration. Superseded.
  • They are very safe
  • Start with a largish dose then wean
  • You cannot become ‘dependent’ on them
  • There is no such thing as ‘lazy bowels’ from laxative use.

Infant period – 4-12 months

Triggers include starting formula or solids

  • Diet – Rice based cereal, and banana can contribute to constipation. Change to oat based cereal and use prunes, dates, pears and other fruits. 
  • Temporarily soften the stool 
    • Mild – Moving to formula and solids can sometimes result in mild constipation. Using pear and prune juice is sometimes all that is needed. Occasional use of a glycerine or half a microlax enema for the infant who appears distressed and uncomfortable is also acceptable.
    • Moderate – For infants who have ongoing issues Give actilax 3-5 mls per day mixed with water, formula, or juice
    • Severe – If ongoing problems with constipation seek medical advice to rule out a medical cause. Sometimes cow’s milk formulas can trigger constipation, so trial of soy formula maybe necessary.

Early toddler period – 12 – 24 months

Triggers can include commencing cows milk or too much dairy.

  • Mild – Decrease cow’s milk consumption to 300 mls per day and short term use of actilax 5-10mls daily. Encourage fruits with skin on (apricots, prunes, peaches, plums) and encourage water
  • Moderate – Revert to formula if bowels were healthy as an infant. Actilax 10mls daily for a period. Wean very slowly. Fruits as above
  • Severe –  If ongoing problems despite aggressive treatment consider assessment for medical causes. This may include blood tests checking for coeliac disease, thyroid or calcium issues.

Toddler period – 24 – 36 months

Triggers include passing painful hard poo – diet, illness, lifestyle and toilet training. 

  • Mild – Decrease cow’s milk if consumptioin is more than 300 mls per day.  Soften stools using either  Movicol junior (half) one satchet per day, or osmolax one small scoop per day.  Encourage fruits with skin on (apricots, prunes, peaches, plums) and encourage water. Double dose of stool softener if no improvement after 48hours. 
  • Moderate – For those who have long term problems –  start a ‘cleanout’ with two to three movicol junior satchets per day or two to three small osmolax scoops per day. Sometimes several days of this are needed. When success, revert to an effective dose (1-2 per day). Wean slowly over several weeks (months)
  • Severe – If ongoing symptoms then seek medical advice from GP or paediatrician

Toilet training constipation

This period can be complicated by trying to toilet train. Toilet refusal, coupled with hard bowel actions will quickly result in constipation issues. This will exasperate parents, who can contribute to the constipation if toilet training becomes coercive or a negative experience. Constipation occurs as toddlers fear using the toilet or opening their bowels. They may ‘save up’ their bowel actions for a night nappy or go and hide so ‘no one notices’.

Management

  1. Stop toilet training. Revert to nappies for a period. Fixing the constipation is a priority and toilet training can be tackled later. The goal is to ensure painfree stressfree poos. Set up a reward system to achieve the following steps
    • Firstly the child will communicate when they need to open their bowels. The parent will praise this and place a nappy on the child unless one is already in place.
    • Once this has occurred and the child is communicating successfully, the next step is to get the child to use his nappy in the room where the toilet is. This may entail an ‘upping’ of the reward system.
    • Next the child can use the nappy whilst sitting on the toilet, so getting used to this position when opening their bowels. Make sure toilet sitting is comfortable with foot stool in place to support the feet
    • Finally the nappy can have a hole cut in it or maybe even removed.
      These steps require patience, a positive attitude, and ensuring there is little ‘talking’. Keep things very simple and try to remain calm.
  2. If significant constipation use one to two satchets of movicol junior or one to two scoops of osmolax per day to get things moving
  3. Ensure adequate fluids and fruit. Diminish excess dairy

The young child

This age group may have had the odd constipation episode, but things can deteriorate when they attend kindergarten, prep or grade one.  Sometimes they can be so ‘busy’ they will ignore the bodies messages to go to the toilet, and after a while the build up will result in constipation.

  • Regular toilet sitting 20 minutes after meals for at least 10 minutes, using a timer. Use incentives and rewards, particularly if there is a bowel action.
  • Soften the stools with good doses of osmotic laxatives. Suggest commencing with 2 junior satchets of movicol or two small scoops of osmolax per day
  • Ensure diet contains adequate fibre and  sorbitol, for example fruits such as apricots, prunes, dates. lessen dairy and high fat foods
  • If there is fear of toilets at school or kindy, practice using other toilets. Sometimes it is useful for the parent to take the child outside school hours so they get used to using toilets in new places.

The Older Child with Encopresis

Encopresis means soiling of underwear which is involuntary. By definition it implies children over the age of 4years.  It is due to long term constipation, and the child has lost the ability to be aware that he needs to go to the toilet. The lower end of the large intestine and the rectum have become so dilated that the child is unable to know when to go to the toilet. In this instance some ‘looser’ faeces will ‘break through’ and  soil the underwear which is particularly distressing to the child and his family. The management of this is complex.

 

The principals for managing this are similar to above.  There is a very good diary and explanation at Royal Children Website Encopresis Diary.

  1. See an experienced health professional to assess the encopresis, examine the child and rule out any medical factors
  2. Sort out any dietary issues.
  3. Commence a cleanout regime using the osmolax or movicol as mentioned above, but the doses sometimes are extraordinarily high. For example in some cases up to 6 – 8 scoops of osmolax are required if there is limited success with lower doses.  During this period the child needs to be kept home so they can concentrate on emptying their bowels in a comfortable environment. This may take several days. In extreme cases the child is admitted to hospital for a ‘cleanout.
  4. Use the above guidelines for regular toilet sitting.
  5. Once the cleanout has been successful remember it may take several months before the normal function of the bowel returns.  This means that softening agents will be needed constantly. The most common mistake is for parents to cease the medication feeling that it is no longer needed.
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