What is Constipation anyway ?
There are different definitions in some dictionaries it's defined as a condition in which bowel emptying occurs infrequently or in which the stools are hard and small or where bowel movement causes difficulty or pain.
Doctors prefer using a practical working definition such as the irregular bowel movements (passage of stool ) less than 3 times a week , frequently associated with difficulty, straining and discomfort during defecation.
Here are some facts that Mothers should know about constipation :
Children who are Breast fed have an average of three stools per day.
Bottle fed Babies have an average of two stools per day.
As long as your Child has no pain, does not strain during defecation and stool is not hard ,infrequent defecation (e.g. every other day) should be considered normal.
What your doctor may ask in the history :
Take a detailed and careful dietary history as this plays a significant role in constipation.
Your social and family history will also be asked and it's important that you give a detailed history as this will give a clue to the problem.
For instance you may be asked ,if there was a delay in passing meconium -the first stool of a new born baby within 48 hours .
Constipation at a very early age which may suggest something more sinister for example Hirschsprung's Disease which is associated with failure to thrive, abdominal distension and vomiting.
Does your child have adequate fibre rich food and daily fluid intake ?
Does your child have Cow's milk intolerance (more commonly associated with diarrhoea) ?
Is your child on any regular medications?
He may also want to exclude other possible causes.
An adequate social history is essential , for instance fear of defecation .
Previous pain or coercive potty training may cause toddlers to withhold defecation.
Domestic stress or lack of privacy (For example in school lavatories) may do the same for older children.
Your Doctor should also exclude painful anal problems such as fissures, perianal skin infection, sexual abuse as possible causes of the constipation.
Examinations usually carried out:
Palpation ( feeling with the palm) of the abdomen may demonstrate distension or faecal loading.
Digital Rectal examination is usually not recommended in children unless in exceptional circumstances.
Plain abdominal X-rays are not recommended (except to confirm faecal impaction and overflow where the presentation is diarrhoea).
Studies like - Solid marker transit, are occasionally necessary where rectal retention or colonic inertia is suspected (child swallows radio-opaque markers over 3 days and X-ray taken on day 5).
Management of Constipation in Children
Remember normal children have a wide variation of frequency of defecation and hardness of stool.
Treatment is aimed at those with pain on defecation, severe straining, overflow incontinence or soiling. The cause if known should be treated.
Your Doctor will encourage diet rich in fibre with adequate fluid intake - unless the cause is gastrointestinal obstruction, mega colon, or colonic inertia/hypotonia.
If diet alone is unsuccessful your Doctor will then consider medication .
Stool softeners/osmotic laxatives initially (eg lactulose) or bulking-forming agents (eg ispaghula husk, methylcellulose).
If these fail, he may consider adding in a stimulant laxative (e.g senna, bisacodyl or sodium picosulfate syrup); as combination therapy (e.g lactulose and senna) may be effective where single drugs fail.
Treatment may be needed for many months, with the doses slowly being reduced to reduce the likelihood of re-impaction. More extreme measures include the use of bowel preparation techniques ( Picolax® - unlicensed indication) or manual evacuation under GA. When Your Doctor will consider referring your child to Paediatric Specialist? :
If constipation is prolonged (>6 months), Treatment unsuccessful,
Frequent soiling and distress,
The constipation is interfering with school or social relationships.
He may also involve community paediatric nurses where available, with health visitors and/or school nurses and social workers to provide support network for child and family.
Severe psychological problems may need the help of child psychologists.Psychological problems such as distress ,depression ,anxiety and others.
When will your Doctor consider referring your child to a Paediatric Specialist ? :
If constipation is prolonged (more than 6 months) and treatment has been unsuccessful,
Frequent soiling and distress.
The constipation is interfering with school or social relationships.
The Doctor may also involve community paediatric nurses where available, with health visitors and/or school nurses and social workers to provide support network for child and family.
Severe psychological problems may need the help of child psychologist.
Dr Jacqueline A
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