C h i l d r e n and

Children
and
Constipation
Normal bowel habits are a sign of health in children. Parents
pay close attention to how often their children have a bowel
movement (BM) and what it looks like. Anything out of the
ordinary may be cause for a trip to the doctor. But how do you
know when and when not to worry?
This pamphlet will help you understand what is constipation and
possible treatment options.
What is constipation?
• as stools stay in the colon they become bigger and harder,
Constipation is very common in children. It is not a disease and it can
be resolved.
Constipation often becomes a family problem because when a child is
constipated the entire family may find the situation stressful.
Constipation can be defined as:
• a decrease in frequency of bowel movements, 2 or less times/week.
• stools that are hard, dry and shaped like balls, pebble-like stools.
Even if this occurs daily.
• stools that are painful and
•
•
difficult to pass.
very large stools that can
block the toilet.
with or without soiling
underwear.
•
stretching the colon. The stools then are more difficult and painful
to pass. This creates a cycle of: bowel movement = pain.
child continues to hold in his/her stool.
What are the symptoms of constipation?
•
•
•
•
•
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painful bowel movements
stomach pain/abdominal bloating
rectal bleeding from tears (fissures)
poor appetite
irritability/crankiness
urine problems (recurrent infections,bedwetting, retention).
AVERAGE FREQUENCY OF
NORMAL BOWEL MOVEMENTS
Age
# of times/day
0-3 months
6-12 months
1-3 years
4y & older
2-3
2
1.5
1
The most common cause of
constipation is functional and
not due to an underlying disease. Functional constipation begins
when a child has a painful bowel movement . The child then holds in
the next bowel movement because of the pain he/she previously
experienced.
THE FUNCTIONAL CONSTIPATION CIRCLE
Holding/retention
After a child passes a stool that causes pain he/she will not want to
have another bowel movement. So the child will start holding. This
holding/ retention often becomes an unconscious and regular habit.
What are the signs that your child may be holding
a bowel movement?
• it may look like your child is trying to push, however he/she is
•
•
•
•
•
•
•
•
probably trying to hold the stool in.
hiding in a corner/holding on to furniture.
wriggling on the floor/unusual positions.
crossing their legs.
their body is stretched and clenched/up on their toes.
dancing back and forth from one leg to another.
they may clench their buttocks.
refusal to have a bowel movement.
fear of the toilet.
Possible causes of holding/retention
• child feels the need to have a bowel movement (BM).
• child holds in his/her stool for fear of pain.
• urge to go passes.
2
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•
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•
•
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•
•
•
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previous painful anal experience
toilet training
stressful event
changes in the diet/routine
travel
viral illness/gasto-enteritis
bad diaper rash
starting school / summer camp
hard stools, suppositories, enemas, dilatations
ignoring the urge to go for a bowel movement/too busy
toilet not available
use of certain medications
sexual abuse
3
Complications of constipation
Encopresis
Fecal impaction:
• uncontrolled release of stool in underwear.
•
•
•
•
•
This is not a defiant behaviour. Your child cannot feel what is
happening.
Cause: when a stool is so big it stretches the rectum, the
sensation to have a bowel movement decreases. When this
happens, liquid or soft stools seep around the large stool mass.
This leaks out without the child feeling it. This is a common
complication of severe constipation and may be confused
with diarrhea.
•
accumulation of a large, firm stool mass called a fecaloma
found during a physical exam and/or abdominal x-ray
the stool is difficult or impossible to pass
Symptoms: > abdominal pain/bloating
> sensation of rectal fullness
> nausea and vomiting
> encopresis
if left untreated it can become big enough to provoke intestinal
blockage and urinary problems.
Fissures:
Rectal prolapse:
• a superficial cut in the lining of the anal canal caused by excessive
• rectal lining that bulges through the anus. This is caused by
•
stretching during the passage of a large, hard stool.
Symptoms: > severe pain or burning sensation
> pain during and after a bowel movement
> anal itching
> bright red blood on stool or toilet paper
•
Hemorrhoids:
• hemorrhoids are veins that are a normal part of the human body
but they become dilated and visible when increased straining
• hemorrhoids can be internal and/or external
• External hemorrhoids are the most common in children . There
are no symptoms.
• Symptoms of internal hemorrhoids:
> are more obvious in older individuals
> are revealed as a bulge outside the anus and by
bleeding and itchiness around the anus.
increased abdominal pressure when straining. It may also be
a result of weakness or stretching of the muscles that support
the rectum.
Symptoms:
> a mass bulging from the rectum when the child
is having a bowel movement. It looks like a donut
with wrinkles.
> mucus discharge
> rectal bleeding
> fecal incontinence
> most frequently due to constipation and
repeated straining, but could be due to diarrhea,
parasites and various diseases
Failure to thrive:
Constipation can cause fullness. This may decrease your child’s
appetite, which could affect his/her weight gain. If there is a severe
decrease in growth, other causes of the constipation need to be
looked at.
Psychological complications:
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•
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4
decreased quality of life
decreased self esteem
social withdrawal
denial is often a coping style
5
Other conditions
Treatment
Infant Dyschezia
1- Education / demystification
2- Disimpaction (not always necessary)
3- Maintenance
• at least 10 minutes of straining and crying before successful
•
•
passage of a soft stool. This occurs in an otherwise healthy infant
less than 6 months old.
it is the result of incoordination between increased abdominal
pressure and pelvic floor.
it resolves spontaneously with time.
a. Behavioural Modification
b. Diet
c. Exercise
d. Medication
4- Wean/Observe
Hirschsprung Disease:
Normally, muscles in the intestine push stool to the anus. Special
nerve cells in the intestine, called ganglion cells, make the muscles
push. A person with Hirschsprung Disease (HD) does not have these
nerve cells in the last part of the large intestine.
In a person with HD, the healthy muscles of the intestine push the
stool until it reaches the part without the nerve cells. At this point, the
stool stops moving. New stool then begins to stack up behind it.
Hirschsprung is typically diagnosed soon after birth however it may
go undiagnosed until childhood. It may be associated with bloating
and possible growth retardation and may present as a constipation
which is very hard to treat.
Compared to functional constipation there is also the absence of
significant encopresis. Rarely are the stools large, they are more
“ribbon-like”. It is also rare to have holding/retention behaviour.
Treatment requires surgery to remove the affected area.
1-
Education / demystification
Treatment of constipation requires patience and time. Retraining is
needed to make the body/brain forget the pain when having a bowel
movement. This is a long process with gradual improvement and
relapses. Any painful bowel movement can result in a relapse. Our
healthcare team is here to coach and support your child and yourself.
This includes follow-up visits and phone calls. We encourage parents
to maintain a consistent, positive and supportive attitude in all
aspects of the treatment.
2-
Disimpaction
• may be necessary before maintenance therapy.
• accomplished with either oral or rectal preparations . The oral
•
approach is favoured because it is not painful and it gives the
sense of power to the child.
discussion with you and your child will help in choosing the
best option.
The longer constipation
goes unrecognized,
the more difficult
it is to treat.
6
7
3-
Maintenance
3a. Behaviour modification
• Start regular toilet sessions 2-3 times/day
• Encourage unhurried time after meals for bowel movements
• Encourage child to go to the toilet when the urge is felt (avoid
holding/retention)
• Keep a diary of stool frequency –this can be used as positive
reinforcement by parents and doctor
• Use a reward system – stickers on a calendar chosen by
your child
CLASSIFICATION
LUBRICANTS:
Mineral oil
Lansoyl
ACTION
• softens and covers
the stool making it
difficult to hold and
easier to push out.
• it is not absorbed
by the body.
• it is NOT
recommended
for children under
1 year old.
• special precautions
must be taken if
your child is
refluxing or is
handicapped.
• the dose may be
divided and taken
anytime during the
day but
AVOID giving it
before bed.
• it can be mixed
with any type
of food.
• theoretical
interference with
the absorption of
minerals and
vitamins.
• leaking of oil in the
underwear may be
an inconvenience
of this medication.
• lactulose is a sugar
that is not
absorbed.
• lactulose provokes
the colon to secrete
water which
stimulates
contractions of
the colon.
• also acts as a stool
softener.
• side effects:
flatulence and
cramping if dose
increased too fast.
• MOM: infants
susceptible to
magnesium
poisoning, use
caution in renal
impairment.
• sorbitol is also
found in some
juices-apple, prune,
pear.
• mimicks a diet rich
in fibre.
• acts like a sponge
when in contact
with water. This
increases the size
of the fecal mass.
• the larger mass
stimulates
contractions of the
colon.
• the child must be
well hydrated and
active for best results.
• must be taken with
plenty of liquid to
avoid increased
constipation or
intestinal blockage.
• absolutely do not
use in patients with
intestinal
obstruction or
narrowing.
3b. Diet
We favour a balanced diet but we do not recommend forcing the diet.
• You can enrich the diet with fibres as recommended by the
Canadian Food Guide. Simply follow this formula:
AGE + 5 = total amount of grams of fibre/day
• Drink plenty of liquids during the day
3c. Increase exercise
3d. Medication
It is beneficial to add oral medication to behaviour modification. This
will achieve positive results sooner. Finding the right medication and
dosage may be difficult and long. But once the right “formula” is
found your child will stay on this for about 4-6 months or longer.
When your child has been having regular bowel movements, without
difficulty, the medication can be slowly decreased and then stopped.
Your doctor will decide when your child should be weaned from the
medication. This will also be a slow process so a relapse will not occur.
OSMOTICS:
Lactulose
Milk of magnesia
(MOM)
Sorbitol
Citro-Mag
The most common medications we use to start a treatment are:
mineral oil, lansoyl, lactulose and PEG 3350. They are safe and
effective. We do not recommend suppositories or enemas as this is
a painful experience, which favours the circle of “pain and holding”
described earlier. Use these only when recommended by your doctor.
MUCILAGES:
Fibre substitute
Metamucil
Prodiem
Benefibre
COMMENTS
...continued on page 10
8
9
CLASSIFICATION
EMOLLIENTS:
Colace
ACTION
• softens stools.
• easier to push out
the stool.
COMMENTS
• DO NOT use in
combination with
mineral oil to avoid
absorption of the
mineral oil.
Tricks to remember
• Treatment takes time. Don’t get discouraged, it is a gradual
process and relapses may occur.
• The secret to the success of treatment is to take the treatment
properly and DO NOT STOP it too fast.
STIMULANTS:
Dulcolax
Senekot
Ex-Lax
RECTAL
PREPARATIONS:
Suppositories
• Glycerine
• Dulcolax
Enemas
• can provoke
cramps and
diarrhea.
• use intermittently
and for short
periods of time
only under the
recommendation of
your physician.
• if used often these
medications can
cause a “lazy
bowel“ which is
difficult to reverse.
• A normal stool has the consistency of toothpaste or peanut butter.
• Try to have daily bowel movements to prevent build up. This allows
• stimulate and
lubricate.
• main action is to
increase the size
of the rectum and
provoke the
sensation of the
need to go.
• to be used
occasionally for
constipation.
• risk of mechanical
trauma to rectal
wall.
• when this
medication is
needed your
physician will
recommend which
one to use.
• perpetuates
“viscious circle of
pain and then
holding”.
• DO NOT use soap
suds, tap water or
Mg enemas.
•
• provoque diarrhea
(osmotic agent)
• may be difficult to
take due to bad
taste and amount
or quantity
required.
• may cause nausea,
cramps, vomiting.
• stimulates
intestinal nerves
therefore provokes
contractions of the
colon.
• produces drastic
effects in emptying
the intestines
quickly.
the rectum to return to normal size.
• Stop holding/retention behaviours.
• Adopt the habit of checking food labels for fibre content.
• You can refer to our fibre sheet . This gives quantities and grams of
fibre for many different foods.
• Increase fibre intake gradually. At the same time increase fluid
•
•
intake, to prevent your child from becoming more constipated.
Parents need to maintain a consistent, positive, supportive attitude
in all aspects of treatment.
Promote responsibility and independence for going to the
bathroom.
Our team is there for YOUR CHILD AND YOU.
LAVAGE:
Polyethylene glycol
(electrolyte solution)
• Peglyte
• Golytely
• Colyte
Polyethylene glycol
powder (PEG 3350)
(without electrolytes)
• LAX-A-Day
• Miralax (US)
• Forlax (FRANCE)
• Movicol (ENGLAND)
10
• osmotic agent.
• cause water to be
retained in stools.
• make stool soft.
• increase frequency
of stool.
• easy to take.
• safe.
Bibliography
Baker S. S and al.
A medical position
statement by NASPGHAN.
Constipation in infants and
children: Evaluation and Tx
JPGN 29:612-626
Hyman P. and al.
Childhood Functional
Gastrointestinal Disorders:
Neonate/Toddler.
Gastroenterology 2006;
130: 1519-1526.
Rasquin A. and al.
Childhood Functional
Gastrointestinal Disorders:
Child/Adolescent.
Gastroenterology 2006;
130: 1527-1537.
Sleisenger and Fordtran’s
Gastrointestinal and Liver
Disease 7th Edition.
Wyllie/Hams
Pediatric Gastrointestinal
Disease Second Edition.
11
This booklet was prepared by Dr. Dominique Levesque, M.D., pediatric
gastroenterologist and Director of The Montreal Children’s Hospital
Motility Lab and by Sandra Kambites, RN, BScN Motility Lab Nurse. It was
reviewed in collaboration with the Gastroenterology Service and the
Department of Surgery. Special thanks to Dr. Jean-Martin Laberge.
Funding for this booklet was made possible thanks to the Auxiliary of the
Montreal Children’s Hospital of the MUHC.
2300 Tupper Street
Montreal, Quebec H3H 1P3
514.412.4400
www.thechildren.com
April 2009
IMPORTANT : S.V.P. LIRE
L’information fournie dans cette brochure sert à des fins
éducatives. Celle-ci ne doit aucunement remplacer les conseils
ou directives d’un médecin / professionnel de la santé, ou servir
de substitut à des soins médicaux. Veuillez communiquer avec
un médecin / professionnel de la santé si vous avez des questions
concernant votre état de santé.