What is constipation?
Constipation is either a decrease in the frequency of bowel movements (BMs), or the painful passage of stool. "Normal" stool frequency can vary from three times per day to three times per week, as long as stools are soft and easy to pass. If a child is constipated, stools are often hard and the child must strain to pass them.
Why is it a problem?
If a child has infrequent BMs, or stools more regularly but only in small amounts, stool begins to collect in the large intestine (colon). This causes stretching of the colon, which makes it less effective at pushing stool out. It also allows more stool to collect in the colon, making the problem worse. When children pass large, hard stools it can cause pain which leads to fear of having a BM and withholding. All of these issues can create a cycle that worsens the constipation.
How common is constipation?
Although it is not always discussed, constipation in children is very common. About 3% of all visits to pediatricians and 25% of all visits to pediatric gastroenterologists are related to constipation.
Why does constipation happen?
Infants may have more difficulty passing even soft stool because of immature and undeveloped muscles. This does not necessarily indicate a serious or life-long problem. Also, it can be normal for breast-fed babies not to pass stool for several days.
As children get older, constipation can occur because of dietary factors, such as not having enough fluids or fiber. It can also develop as the diet changes, such as when solid foods or whole milk are added. Other factors, such as travel, illness, or not wanting to use a bathroom outside of home can also contribute.
In some younger children, a painful BM can start a process of stool withholding. The child is fearful of having another painful stool, and when they sense the need to have a BM they will stiffen, "dance" or do other things to prevent passing stool. Eventually the feeling will go away but the stool collects in the colon and becomes more firm. When they eventually have a BM it is even more painful, and the cycle continues. Older children can withhold for reasons discussed above. Some children eventually lose the sensation of needing to have a bowel movement.
What is encopresis?
When constipation has been present for some time and a large amount of stool is in the colon, soiling of the underwear or leakage of stool can occur. This is called encopresis. It happens because liquid or soft stool passes around hard masses of stool that are present in the colon. The child is often surprised when stool is passed. It can be mistaken for diarrhea, but it is actually related to constipation and needs to be managed aggressively. Some children with wetting have constipation as well. This problem can understandably be very stressful for the child and/or family.
How can we be sure nothing else is wrong?
A very large majority of children with constipation have what is called "functional" constipation. It develops in the ways described above, and there are no underlying problems with the intestines or other body parts.
Rarely, children will have other problems that cause constipation. These can be structural problems with the intestine, or problems with the nerves, spine or thyroid. There are almost always clues to these types of problems in the history or physical exam, and often other invasive tests are not necessary. If your provider has concerns, blood or X-ray tests will be ordered to rule out other problems.
How is constipation treated?
Treatment usually focuses on clearing stool from the colon ("cleanout"), keeping stools soft and easy to pass, and developing good toilet habits. There are physical and often psychological or behavioral issues to consider. Constipation usually does not develop quickly and usually does not resolve quickly, but steady progress should be seen.
Removing the excess stool from the colon is needed to help make the daily treatment work best. Enemas may be used for this. Laxatives may also be used and are a general term for medications that either change the consistency of the stool or stimulate the bowel to move stool. Examples of these medicines include polyethylene glycol (Miralax®), senna (Senekot®), bisacodyl (Dulcolax®), and magnesium citrate.
The cleanout process is very important to make other medicines work better. Sometimes an abdominal X-ray will be ordered to be sure the cleanout was effective. It may need to be repeated if constipation reoccurs. Please let your provider know if your child is not able to tolerate the cleanout.
Occasionally, constipation is so severe that treatment at home is not likely to be effective. In these cases, children are admitted to the hospital for a brief time. Usually a tube, called a NG tube, is placed through the nose into the stomach and large amounts of a strong laxative are given. This continues for several hours until all stool has been passed, this may take hours or days. Rarely, a more invasive procedure called manual disimpaction is needed, where the child is given medicine to sleep and then some stool is physically removed by the doctor. The NG tube and strong laxative is then used until all stool is passed.
Daily medicines for constipation focus on making stool soft and easy to pass. Most either hold more water in the stool or coat the stool to keep water from being absorbed in the intestine. This keeps the stool softer, which allows the body to move and pass stool on its own. They are very safe for long term use.
Aggressive stool softening therapy is very important, especially if stool withholding is present. It may need to continue for months or years to help children to stool regularly and prevent constipation. It can be tempting to stop the medicine as soon as the child seems better, but it often takes months or longer to fully resolve all of the problems with constipation. Medical therapy may need to be frequently adjusted during the treatment course.
Common stool softeners include:
- Lactulose/sorbitol (Enulose®)
- Mineral oil
- Milk of Magnesia
- Polyethylene glycol (Miralax®)
The dose may need to be adjusted to find what works best for your child.
It is critical that regular, unhurried times on the toilet occur at least twice a day. This helps to re-train the body to have regular bowel movements. It makes the child slow down and allows them the chance to have a BM. These times do not need to last longer than a few minutes, but need to occur regularly.
It is important that your child receive plenty of non-caffeinated fluids and fiber. Since it can be challenging for children to eat enough fiber, fiber supplements are often used. We can provide you with a list of the fiber content of common foods or with suggestions for fiber supplements if needed.
Instituting regular toilet times and administering medications can be challenging at times. Positive reinforcement using periodic rewards when your child sits on the toilet or has a BM in the toilet can be helpful. Our staff can discuss some basic techniques with you. If a more detailed plan is needed, we can suggest other resources that are available.
- Constipation in children is very common and rarely due to a serious underlying problem.
- Constipation can, however, impact a child and family's daily life in significant ways.
- Constipation does not develop overnight and may not resolve quickly, but on-going treatment can bring resolution.
- Medications, diet changes, and behavioral interventions are all necessary parts of treating constipation.
If you have any questions, please contact our office at 612-871-1145