Health

Treating constipation in children

Constipation is a very common problem for children. For most children, constipation means passing hard stools (faeces), with difficulty, less often than normal. Regular soiling (often mistaken for runny diarrhoea) may indicate that a child has bad constipation causing a blockage of the lower part of the gut (impaction). Where no particular disease or illness is the cause of the constipation, it is called idiopathic constipation. It is important that constipation be recognised early to prevent it from becoming a long-term (chronic) problem.

Your child’s bowels – what is normal?

Parents often become very worried about their child’s bowel habit. This anxiety can start when the child is a baby, with concern over the number of dirty nappies. The main thing to realise is that every child is different. Normal can vary quite a bit. Often, it is a change in what is normal for your child that suggests a problem

Babies will open their bowels anything from several times per day, to once every few days. The frequency of bowel movements is not very important. What is important is that the stools (faeces) are soft and easily passed.

Breast-fed babies tend to pass runnier, mustard yellow-coloured stools. This is because breast milk is better digested than bottle feeds (infant formula). Newborn breast-fed babies may open their bowels with every feed. However, it is also normal for a breast-fed baby to go up to a week without a bowel movement.

Bottle-fed babies often need to open their bowels daily, as the stools are bulkier. Bottle-fed baby stools smell worse (more like an adult’s).

It is not uncommon for your baby’s stools to vary in colour and consistency from day to day. Any prolonged change to harder, less frequent stools might mean constipation.

As babies are weaned to solid foods, their stools will change in colour and smell. The frequency may again change. Generally, the stools become thicker, darker and a lot more smelly. You will notice that your baby’s stools will alter depending upon what you have fed him or her. Some high-fibre foods, such as raisins, may even pass through your baby’s bowels virtually unchanged, appearing in the nappy at the next change.

As your baby grows up, into a toddler and then a young child, you may see further changes in their stool frequency and consistency, often dependent on what they are eating.

Your child’s bowels – what is abnormal?

As you can see, there is great variation in a child’s bowel habit, dependent on their age and what they are fed. As already mentioned, it is often a change in what is normal for your child that suggests a problem. Anything from three times a day to once every other day is common and normal. Less often than every other day means that constipation is likely. However, it can still be normal if the stools (faeces) are soft, well formed and passed easily.

It may be normal for your baby to go a bit red in the face when straining to pass a stool. This on its own does not necessarily mean they are constipated. Breast-fed babies seldom become constipated, as breast milk contains exactly the right balance of nutrients to keep the stools soft and easily passed.

Diarrhoea usually means very runny stools, often passed more frequently than normal. Breast-fed babies have diarrhoea less frequently than other babies, as breast milk has a protective effect against the germs that can cause diarrhoea.

What are the symptoms of constipation?

Constipation in children or babies can mean any, or all, of the following:

• Difficulty or straining when passing stools.

• Pain when passing stools, sometimes with a tiny amount of blood in the nappy or on the toilet paper, due to a small tear in the skin of the back passage (anus).

• Passing stools less often than normal. Generally, this is less than three complete (proper) stools per week.

• Stools that are hard and perhaps very large, or pellet-like and small, like rabbit droppings.

As well as less frequent, hard (and perhaps painful) stools, constipation can cause:

• Tummy ache (abdominal pain).

• Poor appetite.

• Feeling ‘off colour’ (general malaise).

• Behavioural changes, such as being more irritable or unhappy.

• Fidgeting, restlessness and other signs that the child needs to go to the toilet.

• Feeling sick (nausea).

Severe constipation can cause impaction, where a very large stool is stuck in the lower gut, usually just above the anus, in the section called the rectum. This can cause further symptoms. In particular, this can cause a child to soil their pants regularly with very soft faeces, or with faecal-stained mucus. This is often mistaken by parents as diarrhoea. Impaction is discussed in detail later.

What is the treatment for constipation in children?

(Note: this section refers to treatment of idiopathic constipation – the most common type of constipation in children, where there is no known cause. Other types of constipation are explained later.)

Laxatives

Idiopathic constipation that has lasted for more than a few days is usually treated with laxatives. Your doctor will advise on the type and strength needed. This may depend on factors such as the age of the child, the severity of the constipation and the response to the treatment. Laxatives for children commonly come either as sachets or a powder that is made up into a drink, or as liquid/syrup. The laxatives used for children are broadly divided into two types.

• Macrogols (also called polyethylene glycols) are a type of laxative that pulls fluid into the bowel, keeping the stools (faeces) soft. They are also known as osmotic laxatives. For example, Movicol® Paediatric Plain is one brand that is commonly used first. This is mixed into water to make a drink to which cordial, such as blackcurrant squash, can be added to make it taste nicer. Lactulose is another type of osmotic laxative, acting as a stool softener.

• Stimulant laxatives. These encourage (stimulate) the bowel to pass the stools out. There are several different types of stimulant laxative. Sodium picosulfate, bisacodyl, senna and docusate sodium are all examples. Docusate works as a stool softener as well as a stimulant. A stimulant laxative tends to be added in addition to a macrogol if the macrogol is not sufficient on its own.

Laxatives are normally continued for several weeks after the constipation has eased and a regular bowel habit has been established. This is called maintenance treatment. So, in total, the duration of treatment may be for several months. Do not stop the prescribed laxatives abruptly. Stopping laxatives abruptly might cause the constipation to quickly recur. Your doctor will normally advise a gradual reduction in the dose over a period of time, depending on how the stools have become in their consistency and frequency. Some children may even require treatment with laxatives for several years.

Treatment of impaction – if needed

Similar treatments to those listed above are used. The main difference is that higher doses of laxatives are needed initially to clear the large amount of faeces blocking the last part of the bowel (the rectum). Secondly, laxatives are also usually needed for much longer, as maintenance treatment. The aim is to prevent a build-up of hard stools recurring again, which will prevent impaction returning. The enlarged rectum can gradually get back to a normal size and function properly again.

If laxatives are stopped too soon, a large stool is likely to recur again in the weakened ‘floppy’ rectum which has not had time to get back to a normal size and strength.

Treatment to clear impacted stools from the rectum can be a difficult time for you and your child. It is likely that your child will actually have a few more tummy pains than before and that there will be more soiled pants. It is important to persevere, as these problems are only temporary. Clearing the impacted stools is an essential part of treatment.

In rare instances, where treatment of impacted stools has failed, a child may be treated in hospital. In hospital, stronger medicines to empty the bowel, called enemas, can be given via the rectum. For very hard to treat cases, a child can have a general anaesthetic and the bowel can be cleared out manually by a surgeon.

Diet

Dietary measures should not be used on their own to treat idiopathic constipation, as it will be unlikely to solve the problem. However, it is still important to get a child into a habit of eating a good balanced diet. This is to include plenty of drinks (mainly water) and foods with fibre. This will help to prevent a recurrence of constipation once it has cleared.

Does my child need any tests?

Tests are not normally needed to diagnose idiopathic constipation. Your GP is likely to ask various questions and do a general examination to rule out secondary causes of constipation. By examining your child’s tummy (abdomen), a GP can tell if there are lots of stools (faeces) in the bowel. This can give an indication if blockage (impaction – discussed later) has developed. If an underlying cause of constipation is suspected, your GP will refer your child to a children’s doctor (a paediatrician) and further tests may be done.

How can constipation in children be prevented?

Eating foods with plenty of fibre and drinking plenty makes stools (faeces) that are bulky but soft and easy to pass out. Getting plenty of exercise is also thought to help.

Food and fibre

This advice applies to babies who are weaned and to children. Foods which are high in fibre are fruit, vegetables, cereals and wholemeal bread. A change to a high-fibre diet is often ‘easier said than done’, as many children are fussy eaters. However, any change is better than none. Listed below are some ideas to try to increase your child’s fibre intake:

• A meal of jacket potatoes with baked beans, or vegetable soup with bread.

• Dried (or semi-dried) apricots or raisins for snacks.

• Porridge or other high-fibre cereals (such as Weetabix®, Shredded Wheat® or All Bran®) for breakfast.

• Offer fruit with every meal – perhaps cut up into little chunks to make it look more appealing.

• Add extra vegetables to dishes being blitzed with a blender or food processor (for example, Bolognese sauces or soups.

• Use wholemeal/brown versions of bread, pasta and rice.

• Add powdered bran to yoghurt. The yoghurt will feel grainy, but powdered bran is tasteless.

If a bottle-fed baby has a tendency to become constipated, you can try offering water between feeds. (Never dilute infant formula milk that is given to bottle-fed babies.) Although it is unusual for a breast-fed baby to become constipated, you can also offer water between feeds. Older, weaned babies can be given diluted fruit juice (preferably without added sugar). Puréed fruit and vegetables are the usual starting points for weaning, after baby rice, and these are good for preventing constipation.

Encourage children to drink plenty. However, some children get into the habit of only drinking squash, fizzy drinks or milk to quench their thirst. These may fill them up and make them less likely to eat proper meals with food that contains plenty of fibre. Try to limit these kinds of drinks. Give water as the main drink. However, fruit juices that contain fructose or sorbitol have a laxative action (such as prune, pear, or apple juice). These may be useful from time to time (at meal times) if the stools become harder than usual and you suspect constipation may be developing.

Types of constipation in children and babies

Idiopathic constipation. This is common. The word idiopathic means of unknown cause. Various factors may be involved (discussed later) but many children become constipated for no known reason:

• Short bouts of constipation. It is common for children and babies to have a bout of mild constipation for a day or so. This may settle quickly, often without the need for medical treatment.

• Long-term constipation. In about 1 in 3 children who become constipated, the problem becomes more long-term (persistent). This is also called chronic idiopathic constipation.

Constipation due to an underlying disease or condition. This is uncommon. The constipation is said to be secondary to this other problem. Some examples of conditions and problems that can cause constipation are:

• Some neurological conditions.

• An underactive thyroid gland (hypothyroidism).

• Cystic fibrosis.

• Rare diseases with abnormal development of the bowel, such as Hirschsprung’s disease.

• As a side-effect of certain medications that a child has to take for another condition.

References …

patient.info/digestive-health ( Constipation in Children)

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