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Constipation in older children

The cause of constipation in older children is often difficult to pinpoint.

However, several factors may initially have been involved:

• Loss of appetite during an acute illness
• The prescription of constipating medications such as codeine for diarrhoea or fever
• A stressful life event
• Having to rise early and travel long distances to school in the morning
• Children may be anxious about defecating in a particular place, such as an outside toilet or toilets away from home.
• In young children, delay may be caused by stress related to toilet training. Rigid management by parents, including premature training, is a factor.
• Sometimes children resist the urge to have a bowel movement because they are too involved in play and will not take time to go to the bathroom.
• Delay may be part of a more general pattern of oppositional or anxious behaviour.

A major factor is pain in passing stool (including pain from an anal fissure). Children withhold stools out of fear, which causes cramping. Faeces build up, becoming larger and harder the longer they are retained. The rectum gradually becomes distended, reducing sensation and diminishing the urge to defecate.

There is frequently overflow soiling caused by fluid stool and mucus passing around the hard faeces, staining the child’s underwear. Eventually the child will pass a large mass, which may be very painful and require straining.

Constipation can also cause reversible urinary tract abnormalities that may result in urinary tract infection and incontinence.

Because of odour, the child may be teased at school. This can have profound effects on well-being and self-esteem. Parents or teachers may adopt a punitive approach, compounding an unfortunate situation. A special problem is that of chronic constipation in children with mental handicap and neurological disabilities, such as cerebral palsy or spinal cord abnormalities.

Chronic constipation should be suspected when abdominal and rectal examinations show palpable faeces, confirmed by X-rays showing faecal content that may fill the entire colon.
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