The Bristol Stool Chart is a medical aid that helps healthcare professionals classify and talk about stools or faeces. — Wikimedia Commons
Constipation is a common problem in children of all ages.
It can be defined as infrequent passage of stools and/or difficulty in passing hard and painful stools.
To better understand the meaning of infrequent passage of stools, it is helpful to know normal bowel habits.
What is considered to be a normal bowel habit depends on the child’s age and their daily diet.
In the first year of life, breastfed infants averagely have two to three soft bowel movements per day.
There are some breastfed infants who pass stools after every feed, and some who have bowel movements only once a week.
But generally, it is rare to find constipation among fully-breastfed infants.
Formula-fed infants have bowel movements one to three times a day, although sometimes this may depend on which formula is given.
By two years of age, a child typically passes out one to two firm, formed stools every day, and by four years old, they usually open their bowels once every one to two days.
Withholding stool
A child with constipation has stools that are hard, and lumpy or pellet-shaped.
It may be painful during defecation, causing them to cry and strain.
As a result of the pain and discomfort, many children tend to develop unusual habits, including arching their back, crossing their legs, tightening their buttocks, squatting, or adopting other unusual positions, in an effort to avoid bowel movement.
As the urge to have bowel movements comes and goes, the child will constantly shift from playing happily to sudden “attacks” of pain.
Some children will hide in a corner and cry during such periods of pain.
After a painful episode, children may sometimes develop a small tear at the anus called an anal fissure.
This can lead to further withholding of stools due to added pain.
This is a vicious cycle where withholding bowel movement causes larger and harder stools, resulting in a worsening anal fissure.
Most children with constipation do not have any medical problem causing the symptoms.
This condition is termed as functional constipation.
Constipation is more likely in children who lack dietary fibre and fluids, and who lead sedentary lifestyles.
Occasionally, changes in the surrounding environment, such as being at school or travelling, may cause the child to delay their bowel movement as they are not comfortable at the unfamiliar place.
Children who have an allergy to cow’s milk or dairy products may also have constipation, although it is more common for them to develop diarrhoea.
Medical conditions result in constipation in less than 5% of children.
Some of these conditions include hypothyroidism (low thyroid level), hypercalcaemia (high calcium level), Hirschsprung disease (abnormal nerve development in the colon), abnormal development of the anus, problems with absorbing nutrients, abnormalities of the spinal cord, and certain types of medications.
Unplugging the bowels
Some home remedies may be tried first at home if a child has constipation, including:
A diet rich in fibre will help produce softer and more formed stools.
Foods such as fruits, vegetables, and wholegrain cereal and bread, are good sources of dietary fibre.
At least two servings of vegetables and one serving of fruits every day is a sufficient amount.
Fruit juices that include prune, apple and pear, are tasty and easy to consume, and can be served two to three times in a week.
Fibre supplements are available in several forms for some children who may be picky with food.
A child of one year old and above should have at least one litre of fluid per day.
Regular physical activity helps to stimulate bowel movement.
Establishing a toilet routine may be helpful.
Set aside a regular time after a meal each day for the child to sit on the toilet for five minutes.
A foot stool to support their feet with their knees slightly higher than their hips can help to relax the bowels.
Praising the child for their effort is beneficial, even if they did not have any bowel movement.
Remind the child not to withhold their urge especially when they are engrossed in their play.
Meanwhile, the role of probiotics in managing constipation is still being studied.
Due to the many different probiotic strains and their characteristics, as well as the uncertainty of the most suitable and effective dose, there is still insufficient evidence to routinely recommend probiotics in the treatment or prevention of constipation.
If home treatment had not been successful in treating the child’s constipation, it will be helpful to arrange a visit to the doctor.
The medical treatment of constipation involves the following two steps:
Also known as “clean out”, this is often the first important step in order to remove the impacted stools in the bowel, especially for children with chronic constipation.
The treatment may include laxative medications taken by mouth, such as lactulose or macrogol, and sometimes, rectal suppositories.
Oral laxatives are less distressing for children.
It can take up to a week to achieve disimpaction, and so, it is often helpful for school-aged children to take stay home for a few days.
After achieving disimpaction, maintenance therapy is initiated.
The aim is to have soft and spontaneous bowel movements on most days of the week.
Regular laxatives are usually needed for several months to avoid recurrence of constipation from prematurely stopping medications.
The laxatives are then tapered off gradually, as opposed to a sudden cessation, to ensure treatment success.
Dr Yeap Jo Wearn is a consultant paediatrician. For more information, email starhealth@thestar.com.my. The information provided is for educational and communication purposes only, and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this article. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
