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Constipation (Children)

 


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Class
Gastrointestinal system
Description
Constipation is a condition where bowel movements become less frequent and stools (faeces or poo) may be hard, dry and difficult to pass. It is a common digestive complaint affecting people of all ages, and is common in children. Up to 10% of children are thought to have constipation at any one time.

A healthy, regular pattern of bowel movement varies greatly from child to child. Some children do a poo twice a day, others only two or three times a week. In general, a child is considered to be constipated if he or she has fewer than three bowel movements a week. As the number of times that a child poos varies, a better sign of constipation is if the poo is hard, or if the child has to strain a lot to pass the poo or experiences pain when pooing.
Causes
To recognise what causes constipation, it first perhaps helps to understand how a bowel movement normally occurs.

When food is eaten, it is stored for a short time in the stomach and then moves into the intestines or bowels. The walls of the intestine stretch to receive the food from the stomach, and this stretching stimulates muscles in the walls of the intestine to contract. As the muscles contract, the food is squeezed along to the next section of intestine. The process of stretching and muscle contraction is repeated time and time again establishing waves of contraction that drive the food further and further along through the intestines, until it eventually reaches the last section of the intestines called the rectum. These waves of contraction are known as peristalsis. The time that it takes for food to pass along the entire length of the intestines is known as the transit time. The stronger the waves of contraction, the faster the food will move through the intestines and the shorter the transit time.

As the food travels along through the intestines, enzymes break down or digest the proteins, carbohydrates and fats in the food into smaller units that enables these nutrients to be absorbed into the blood stream. Any food that cannot be digested remains in the intestines, eventually forming into faeces or poo which are stored in the rectum. As the amount of poo in the rectum increases, its walls stretch creating a feeling of a need to go to the toilet. The poo is finally pushed out through the bottom or anus during a bowel movement by tensing or straining of the abdominal muscles.

There are a number of different things that can upset this normal process.

A diet low in fibre
Fibre obtained from plant-based foods such wholemeal breads and pasta, brown rice, beans, peas, lentils, oranges, apricots and fresh vegetables is an important part of a healthy balanced diet. Although fibre is not a nutrient and contains no calories or vitamins, it is important to maintain a healthy digestive system. When fibre is eaten, it is not digested but remains in the intestines and absorbs water. As the fibre absorbs water it swells, stretching the walls of the intestine which helps stimulate peristalsis. As a result, the transit time of the food in the intestines is shortened and bowel movements occur regularly. Furthermore, the water absorbed by the fibre also helps soften the poo so it passes out easily through the anus without a lot of straining.

If the diet is low in fibre, for example, if the diet is comprised mainly processed foods such as white bread or white rice and lacks fruit and vegetables, then there is insufficient bulk within the intestines to stimulate peristalsis. The waves of contraction are weak and the transit time of any undigested food is prolonged. The longer that undigested food remains in the intestine, the more water that is absorbed from the poo and the harder it becomes, making it difficult to expel during a bowel movement.

Dehydration
Water is also essential to maintain a healthy digestive system. It increases the bulk of the poo to stimulate peristalsis and softens the poo to make it easier to expel during a bowel movement. Constipation may occur if insufficient amounts of water are drunk each day.

Ignoring the urge to go
A common cause of constipation in children is ignoring the urge to go to the toilet.

In infants, this may occur at the time when they are being potty trained or toilet trained. If the infant does not like the experience of sitting on a potty or sitting on a toilet, he or she may avoid the urge to go. As constipation develops, the child may associate the pain of a bowel movement with the potty or toilet and be reluctant to go.

In older children, constipation may develop when attending school for the first time. They may not like using school toilets, they may not want to stop playing with their friends, their meal times may change and they may not drink as much as they would do at home. All of these changes can upset a child's routine and so affect the number of times a child poos.

The longer a child ignores the urge to go to the toilet, the harder and more painful the poo is to pass. The child may continue to ignore the urge to go and stop straining to avoid the pain. Unfortunately, this may only make things worse. As the walls of the rectum continue to stretch to hold more and more poo, they become less sensitive and stop creating the feeling of the need to go to the toilet. The longer that the poo remains in the child's intestine, the more water is absorbed from it so that it becomes even harder and larger and more painful to pass. So, the child becomes more constipated.

Insufficient exercise
Regular physical exercise helps maintain a healthy digestive system. If children spend too much time playing computer games or watching television, instead of walking or running around and playing, then they may become constipated.

Medicines and medical conditions
Some medicines can cause constipation. These include antihistamines to treat hayfever and allergies, anticonvulsants to treat epilepsy, iron supplements to treat anaemia. On rare occasions, constipation can also be a symptom of other medical conditions.
Symptoms
The size and texture of a child's poo are usually better indicators of constipation than the number of times a child goes to the toilet. If the poo is small, dry and hard and it is difficult or painful for the child to pass then this indicates constipation, although less than 3 bowel movements per week may also be a sign of constipation.

The child may complain of tummy ache or a feeling of being bloated and generally unwell. The child may have a sore bottom and traces of blood may appear on underwear.

The child may avoid going to the toilet, or when he or she does go, may pass unpleasant smelling wind or small amounts of poo and complain later of still wanting to go.

If the child has more severe constipation, the faeces may become impacted and diarrhoea-like fluid may flow past the blockage when they go to the toilet or break wind.
Treatment
Constipation in children is best treated by a change in diet and lifestyle. The child should be encouraged to eat at least 5 portions of fruit and vegetables each day. Low fibre processed foods such as white bread and white rice should be replaced by high fibre foods such as oranges, nuts, multi-grain bread and cereals. Bran added to meals or supplements may be used as additional sources of fibre. As a rough guide, children over 2 years of age should eat 5 grams more than their age of fibre each day, for example a 10 year old child should eat 15 gram (10 + 5) of fibre each day.

At least a litre and a half (6 to 8 medium sized glasses) of water should be drunk throughout the day. The amount of fizzy drinks should be reduced as these tend to dehydrate the body and make constipation worse. Fruit juices such as prune, pear, or apple juice that contain fructose or sorbitol have a laxative action and may be useful occasionally if the stools become harder than usual

Regular daily exercise, ideally 30 minutes of vigorous exercise each day, will help prevent constipation and will also help protect against other illnesses.

A child should never be forced to use a potty or toilet. Instead, if potty or toilet training is turned into a game, for example by rewarding the child by clapping or by putting a star on a chart each time, the infant soon associates it with fun and learns to use the potty or toilet without fuss.

Sufficient time should be allowed for the child to go to the toilet each day, without feeling rushed. A good time is about 1 hour after breakfast when the bowels are most active. Sitting upright on the toilet will make it easier to pass a poo. The child should be reassured about any misgivings about using school toilets and should be told not to ignore the urge to go to the toilet.

If the child has ongoing constipation there are a number of treatments, called laxatives, which
can help. There are a number of different types of laxatives, those that are called osmotic laxatives or stool softeners are the most appropriate for use in children. Stool softeners, such as lactulose and macrogols, draw water into the gut, soften poo and allow it to be passed more easily. Stool softeners are particularly useful it the child experiences pain when going to the toilet. If laxatives are used, they should only be used for short term, occasional constipation. They should not be used continuously unless the child has chronic constipation and is under the supervision of a doctor.
When to consult your pharmacist
Talk to your pharmacist if you want advice about your child's constipation. Your pharmacist will want to know the age of the child affected and how long he or she has been constipated. Your pharmacist will ask you questions about diet and will want to know if any medicines have been taken to try to relieve the constipation. Tell your pharmacist if your child is taking any medicines prescribed by a doctor or bought over the counter, and whether any healthcare supplements are being taken.

Your pharmacist will talk to you about diet and exercise and will be able to advise you if any of the medicines being taken could be responsible for causing constipation.

Almost all laxatives are available without a prescription and, if considered necessary, the pharmacist will recommend a product that is suitable for your child.
When to consult your doctor
Seek medical advice if your child has had symptoms of constipation for more than 2 weeks. A child should see a doctor sooner if the constipation is accompanied by blood in the poo, or if the child is also vomiting, has a swollen tummy or a high temperature as these symptoms may indicate a more serious health problem. Tell the doctor if the pharmacist has advised that some of the medicines being taken may be the cause of constipation, as the doctor may decide to prescribe an alternative product.
Useful Tips
There are a number of measures you can take to avoid your child becoming constipated:
  • Encourage your child to eat plenty of fibre (weight in age + 5 g/day) such as wholemeal bread, cereals, leafy vegetables and beans
  • Reduce intake of processed foods such as cheese and white bread
  • Ensure that your child drinks plenty of water each day and cuts down on fizzy drinks
  • Has a regular toilet routine in the morning and is given sufficient time to go to the toilet. The best time to go is in the hour after breakfast
  • Never ignores the urge to go to the toilet as it will only make stools drier and harder
  • Eats breakfast every morning as this helps to stimulate movement of the bowel
  • Keeps active and exercises regularly

Based on information supplied by: The Digestive Disorders Foundation

Freephone: 020 7486 0341

Supplied by: www.digestivedisorders.org.uk

Reviewed on 27/12/2009


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