Constipation is an important kids’s health issue & often causes real misery for families. Friends and Family may think of constipation as a minor nuisance.
Severe Constipation is one of the most distressing medical conditions to affect children.
Every GP will know of families that have been pushed to breaking point by a child who is unable to attend school because of faecal incontinence.
Why does constipation occur in children?
Most kids with constipation do not have any underlying disease.
Constipation commonly starts around potty training. Discomfort of bowel evacation leads to avoidance which, in turn, leads to retention and larger/harder bowel motions so causing more discomfort, and so on. This is called “functional constipation.” Constipation is also quite common in infants at weaning. Constipation can also start in a child starting school because they don’t want to poo in the school toilets.
Witholding opening the bowels leads to poo building up in the rectum. Water is absorbed from the stool, leading to the accumulation of hard stool that stretches the rectum. Stool loading over time reduces the the sensation of ‘needing to go’ which may cause soiling. And so on … a vicious circle of overloading of stool that becomes hard and leads to more stretching and reduced sensation.
Hirschsprung’s disease occurs when part of the nervous system to the bowel has not developed fully. This occurs in around 1 in 5000 newborns and leads to constipation from early in childhood. The first poo in a baby is called meconium, and babies with hirschprung’s disease will often not pass meconium within the first 48 hours of birth. More rarely, the condition can present in an infant or young child¹ – it doesn’t always present in babies but usually does.
What can I do to help?
Regular toileting – make use of the “gastrocolic reflex” whereby there is a tendency to want to go to the toilet after a meal – so sit the child on the toilet after meals. If the child is old enough to understand rewards then explain that you will reward your child by sitting on the toilet. You can praise your child for actually pooing but the key is reward the process (sitting on the toilet) rather than the “result”. You might want to use stars or another reward system. Be consistent with the rewards. It is important not to punish the child for accidents.
Water requirements for childhood constipation
Age 1-3 years 1300ml/day, 4-8 years 1700ml/day
Food, milk and childhood constipation
Try to maintain an adequate fibre intake (fruit, vegetables, high-fibre bread, baked beans, wholegrain breakfast cerials). Processed bran may cause bloating.
Avoid punishing your child for episodes of incontinence. Rewarding your child for targeted behaviours is helpful. What behaviours might you target?
It’s really important that your child tries to sit for 3-5 minutes on the toilet 20 to 30 minutes after a main meal. During this time, they try to “push out a poo.”
Back Straight, Knees above hips, feet on stool.
The position of the child on the toilet is important – leaning forwards, knees above the hip level, and feet flat on a foot stool or pile of magazines/books.
You can also reward checking the underwear, drinking enough, and/or taking required laxatives. But start with sitting on the toilet.
How might you do this? Firstly, let your child know that you are going to them for sitting on the toilet for 5 minutes. Dig out the sticker chart. Agree a prize in advance. When they reach a certain number of stickers (or stars for older kids) they get the prize. You know your child best. Examples of prizes include watching a favourite TV program, playing a computer game, or visiting a park.
Constipation starting in babies may possibly be caused by cows milk allergy, or allergy to soy milk. This is an area of controversy but your GP may suggest a careful dietary withdrawal followed by a re-challenge.
Why should you see a doctor?
Laxatives is a dirty word to some people. In fact, modern day laxatives are far removed from the laxatives that grandparents may remember using. In a nutshell, laxatives are absolutely essential to allow your child to avoid pain, improve control of bowel opening, and develop healthy habits.
Severe constipation causes soiling. You will need to seek urgent professional attention. The priority is to ‘disimpact’ the faeces with high doses of laxatives. This is a distressing situation for the child and the family. It is important not to stop the disimpaction too early. It takes a few days to achieve brown bitty water. Disimpaction may then be stopped. However, it is essential to continue regular laxatives.
The Maintenance dose is continued after disimpaction has finished. The dose may be adjusted but it is really important to continue the laxative for several months (at least). Some children may require laxatives for several years.
Movicol® Junior (or Movicol® half) is licensed for children 2 years or older (although it is also often used in younger children). The maintenance dose for a child age 1 to 6 is 1 sachet per day adjusted to produce regular soft stools (max 4 sachets daily). This is an “osmotic laxative” and is very safe and well tolerated.
A trial of a combined laxative treatment for paediatric disempaction was published in 2015 in The Journal of Paediatrics & Child Health. The regimen combines movicol with Dulcolax SP.
Sometimes it may be necessary to add or switch to another type of laxative (a stimulant and/or lactulose). Stimulants laxatives include bisacodyl & senokot (both are only available in tablet form) and is added to movicol if needed. Lactulose liquid is considered if the bowel motions are hard.
In some families, constipation is an ongoing problem and very difficult to treat. A certain amount of trial and error may be required and occasionally, a referral to a Paediatric Gastroenterologist will be necessary.