CONSTIPATION IN CHILDREN.

Take heart that modern treatment is usually effective.

childhood constipation doctor brisbane

Constipation in children

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 live normally because of faecal incontinence.

The usual reasons for constipation in children

Most parents of children with constipation will assume that it’s ‘just constipation.’  In other words, the constipation is ‘functional’ and there is no underlying disease. This type of Constipation is often triggered by potty training or a change in childcare or attendance at school.

Chronic constipation is a perfect storm:

  • Retention causes the poo to become larger & harder. Going to the toilet is uncomfortable, leading to  avoidance and thus more retention.
  • The stretched bowel wall results in malfunction of the nerves and muscles of the bowel wall. The bowel doesn’t empty properly and the wall becomes further stretched. There is reduced sensation of ‘needing to go’ which may cause soiling.
  • Poo builds up in the rectum from which water is absorbed. The resulting stool is hard and further stretches the rectum.

Constipation caused by underlyng medical conditions

The vast majority of children with constipation have function constipation described above.

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.

Coeliac disease is quite common and may occasionally present with childhood constipation, and should be considered if constipation starts early on or with the introduction of gluten.

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 not usually 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.

Rare causes also include Imperforate Anus, Cystic Fibrosis, and spinal cord abnormalities.

Training your child to sit on the toilet

Encourage your child to sit on the toilet after meals. This makes use of the “gastrocolic reflex” which we all recognise as a natural ‘call to go’ that occurs at least 15 minutes after eating.

Use a reward system to encourage your child to sit on the toilet. You can praise your child for actually doing a poo but the key is reward the effort of sitting on the toilet rather than the end result which your child may have no control over.

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.”

toilet positioning of child with constipation

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 go about this? Firstly, let your child know that you are going to give them a prize for sitting on the toilet for 5 minutes.

Buy a sticker chart. When your child reaches a certain number of stickers (or stars for older kids) they get the  prize. Prizes include watching a favourite TV program, playing a computer game, or visiting a park.

Water requirements for childhood constipation

Age 1-3 years 1300ml/day, 4-8 years 1700ml/day

Diet

Try to maintain an adequate fibre intake (fruit, vegetables, high-fibre bread, baked beans, wholegrain breakfast cereal). Note that processed bran may cause bloating.

Are laxatives a dirty word?

There is still a very common perception that laxatives should be avoided. This is completely incorrect. However, you do need to ‘do it properly.’

The key laxative used in childhood constipation is the osmotic laxatives. These work simply by increasing the amount of water in the bowel motions. These products are not absorbed into the body.

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. This is a distressing situation for the child and the family. The priority is to ‘disimpact’ the rectum with high doses of laxatives. This takes a few days to achieve. Lower doses of laxatives are then continued for at least 3 to 6 months. Disimpaction takes several days to work, and it might be best to start the treatment at the weekend.

The Maintenance dose is continued after disimpaction has been completed. 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. Osmolax comes in a power that is neutral flavoured.

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.

Incontinence is a very challenging symptom. The continence foundation of Australia provides support for families with children who soil.

References
1: Hirschsprung’s disease – easily missed? BMJ 2012
2: Australian Doctor, 2015
3: NICE guidelines, constipation in children
4: Australian journal of General Practice May 2018

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WRITTEN BY: Dr Richard Beatty
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