Constipation

Constipation occurs when stools become hardened and difficult to pass.

Some people may be concerned about the frequency of their bowel movements because they have been taught that healthy people should have a bowel movement every day. This isn't true. People usually pass stools from three times a day to three times a week. If your stools are soft and pass easily, you're not constipated.

As with adults, the frequency of children's bowel movements varies from child to child. Newborn babies can pass loose, runny stools a couple of times a day or only once a week. Breastfed babies usually have frequent stools and may even have a stool with every feeding. As babies grow older, the number of daily bowel movements usually decreases, and the size of the stools increases.

It is important for parents to realise that there are many "normal" patterns for bowel movements in children. Sometimes children's faces turn red and they appear to strain to pass a stool, but if the stool is soft and the child has no other problems, this is not a concern.

Most children will occasionally become constipated. Usually this is only a short-term problem requiring home treatment. However, some children are frequently constipated (chronic constipation).

What causes constipation?

• A diet that includes too little fibre and/or too little water
• Voluntary delay of bowel movements:
  • 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.
  • Others may be anxious about defecating in a particular place, such as toilets away from home.
  • Delay may be part of a more general pattern of oppositional or anxious behaviour.
  • In the case of young children, delay may be caused by stress related to toilet training.
• The cause of chronic constipation cannot always be identified, but the most significant factor appears to be the painful passing of a stool once constipation has already developed. The longer a bowel movement is resisted, the larger and harder the stool becomes, which may cause pain when it is passed. Children in particular may then withhold stools, which causes cramping. After some time the child may be unable to resist the urge to have a bowel movement and will pass a large mass of faeces. This can be painful, as the child may have to "push hard" during the bowel movement. Passing the stool relieves the pressure until another mass of stool collects and the cycle repeats itself.
• Circumstances such as travelling that disrupt diet, and time and place of defecation.
• Lack of exercise
• Medication
• Pain caused by haemorrhoids and anal fissures
• Laxative overuse
• Irritable bowel syndrome
• Diseases of the metabolism
• Diseases of the endocrine system:
  • Hypothyroidism
  • Excessive amounts of calcium in the blood due to hyperparathyroidism
• Diseases of the nervous system, such as Hirschsprung's disease or diseases affecting the whole nervous system such as spinal cord damage
• Chronic lead poisoning

What are the symptoms of constipation?

• Constipation may occur with cramping and pain in the rectum from the strain of trying to pass dry, hardened stools.
• Some bloating and nausea may occur.
• Sometimes small amounts of bright red blood appear on the stool. This can be the result of anal fissures – slight tearing of the anal membrane as the stool is pushed through the anus – which make the passing of stools very painful. The fissures, which often appear when constipation is chronic, should heal when the constipation is controlled.
• Appetite may be suppressed.
• There may be decreased interest in usual activities.
• Urination may be more frequent because of pressure on the bladder. In the case of chronic constipation, there may be involuntary release of urine (incontinence).
• Occasionally, particularly when constipation is chronic, a stool becomes lodged in the rectum (impacted), with mucus and fluid leaking out around the stool. This can be experienced as constipation alternating with liquid diarrhoea.
• In rare cases, uncontrollable leakage of liquid or loose faecal material (faecal incontinence) occurs and underwear gets soiled. This is called encopresis when it occurs in a child who is past the age of normal toilet training. Some children, out of embarrassment, might hide or throw away underwear.

Can constipation be prevented?

Diet

• Normal bowel function is promoted by eating well-balanced, regularly scheduled meals.
• Eat plenty of high-fibre foods:
  • Increase your fibre intake gradually to allow your body to adjust and to minimise potential abdominal gas or discomfort.
  • Cereals are good fibre sources if they contain 3g or more of dietary fibre per serving.
  • Increase the fibre content of low-fibre foods by adding two to three tablespoons of 100% bran cereal or unprocessed wheat bran to cereal or soup. Add bran and whole grain cereals to casseroles, home-made breads and other baked goods to provide additional fibre.
  • Cooked and raw vegetables and fruits are good choices. Cooking does not greatly reduce the fibre content.
  • Choose fibre-containing snacks, such as whole grain crackers, fresh and dried fruits (apricots, peaches, pears, raisins, figs, prunes, and dates), raw vegetables (broccoli, cauliflower), popcorn, nuts and seeds.
  • Pulses (dried peas, beans and lentils) and nuts are high in fibre and protein. They may serve as high-fibre substitutes for meat, fish or poultry, which have no fibre content.
  • Avoid foods that are high in fat and sugar. Constipation may worsen with diets high in fat, sugar, protein or dairy products.
• Drink enough fluids:
  • The fibre you eat will absorb liquid and keep your stools soft.
  • Drink two to four extra glasses of water per day, especially in the morning. Try to drink at least 1.5 to 2 litres of liquids throughout the day in the form of water, juice, milk, soup or other fluids.
  • Prune juice may be helpful as a mild laxative.
• For babies and young children:
  • Breast-feed your infant; constipation is rare in breast-fed infants.
  • Make sure you are adding the correct amount of water to the infant's formula. For infants under six months give additional water (up to 60ml twice a day).
  • From the age of six months, give your infant prune juice. Start with 2.5ml and slowly increase the amount to 60ml. From nine months, add one to three tablespoons of strained prunes per day. Alternatively, give infants from six to 12 months of age 60ml to 120ml of fruit juice, such as grape, pear, apple, or cherry, twice a day.
  • Make sure your child is not eating or drinking too many dairy products, such as milk, ice cream, cheese and yoghurt. At age one, a child needs four servings a day.

Exercise

• Exercise more. A walking programme is a good start.

Habits

• Set aside relaxed times for having bowel movements. As urges usually occur after mealtimes, it may help to ask a constipated child to sit on the toilet after meals, especially breakfast. It may help to make this a daily routine.
• Defecate when you feel the urge. When a stool needs to pass, your bowel sends you signals. If you ignore these signals, the urge will go away and the faeces will eventually become dry and difficult to pass.
• A firm footing, perhaps with the aid of a footstool, helps children position themselves properly on the toilet.

When to see your doctor

Contact your doctor if:

• Rectal bleeding is heavy (more than a few bright red streaks on the surface of the stool)
• The blood is dark red/brown/black
• Blood is mixed with the stool
• Rectal bleeding continues for more than two to three days after improvement of constipation, or if bleeding recurs
• Constipation is accompanied by severe pain in the abdomen, nausea or a swollen abdomen
• Rectal pain continues longer than 30 minutes after a bowel movement or prevents you from having a bowel movement
• Uncontrolled leakage of stool occurs
• Acute constipation or other bowel habit changes persist after you have tried home treatment and prevention measures for one week for adults or three days for children
• Constipation has become chronic; chronic constipation is worsening, causing new problems, or is accompanied by other bowel habit changes (changes in the size, shape, or consistency of your stools)
• You are unable to have bowel movements without using laxatives
• There is any change in your bowel habit that cannot be ascribed to a change in diet or drug therapy

Visit preparation
The answers to the following questions will help your doctor diagnose and treat constipation:

• When did the constipation begin, and has it been a chronic problem?
• How often do you normally have a bowel movement?
• Are the stools hard or soft?
• Is there a history of constipation?
• What treatment have you tried, and have prevention and home treatment measures brought relief?
• If your child has been toilet trained, has she had any leakage of partially formed or liquid stool that has soiled her underwear?
• Has there been a recent change in diet or fluid intake, a decrease in activity level, or introduction of new medication?
• Have you or your child recently changed your daily routine, for example by changing jobs or schools, or by travelling?
• Have you had any very stressful events recently?
• Do you have any accompanying symptoms, such as rectal bleeding, abdominal pain or bowel habit changes (changes in the size, shape, or consistency of your stools)?

Treatment

Home
Occasional constipation can be treated effectively at home:

• Follow a fibre-rich diet to help relieve and prevent constipation.
• If your child has rectal pain because she is unable to have a bowel movement, you can try adding 60ml of baking soda to a warm bath. The baking soda and the warmth may help relax the anal sphincter (muscular valves that normally keep the stool inside the rectum) and thus help pass the stool.
• Bulking agents such as bran and psyllium are not laxatives, but work by increasing the volume of stool and making it easier to pass. These products are safe to use and regular use renders them more effective. Always drink plenty of water when taking bulking agents.

Warning symptoms to watch for during home treatment:

• Constipation or changes in the stool that persist after 24 hours of home treatment in an infant younger than three months
• New constipation that persists or other bowel habit changes that continue after one week of home treatment.
• Rectal pain that develops, increases, or lasts longer than one week
• Development or increase of abdominal pain
• Increase of blood in the stool or appearance of blood for longer than one week
• Increased severity or frequency of symptoms
• Other bowel habit changes (changes in the size, shape, or consistency of your stools): this may be a sign of bowel cancer
• Uncontrolled leakage of faeces

Medication

• Laxatives work by irritating the lining of the bowel, which speeds up the passage of faeces. Regular use is not recommended, as it decreases tone and sensation in the large bowel, causing laxative dependence. Take with water.
• Your doctor may recommend a laxative or stool softener if improvements in diet and toilet habits do not ease the constipation. Do not use liquid paraffin or any other laxative for more than two weeks without consulting your doctor.
• Do not give laxatives or enemas to your child without talking to your health professional first. Children should not need an enema or a laxative to have a bowel movement.

Other

• Chronic constipation usually requires several months of treatment and co-operation among parents, the child, and the health professional. It is important for parents to talk openly to their child. This can be difficult because children are often embarrassed and may avoid talking about the problem or even deny it.
• Parents should not be discouraged if the constipation recurs during these months. As the rectum is a muscle, it becomes stretched in chronic constipation and might require several months to return to normal.
• If your child is encopretic, consult a clinical child psychologist. Possible underlying psychological problems can be treated with child psychotherapy.

Diseases that affect the nervous system will not respond to the usual treatment for constipation and it must be dealt with by specialists in these fields.