Children’s Constipation

Constipation is a frequent problem in children and up to 80% of 80 year olds have signs of chronic constipation in South Australia. This brochure aims to assist you in managing your child’s constipation. It is not intended to replace a consultation with your doctor, but to make sure you get the most out of the consultation. In this brochure a “bowel action” means the same as “doing a poo”. You may have your own term.

What is constipation?

1 Dr Kathy Lee, General Paediatrician Updated Jan 2015

Once food has passed through our stomach into our small bowel (intestine), a large amount of water is added to help digest and absorb the food. Our large bowel (colon) is designed to reabsorb water. This makes a formed stool that we pass. In adults, the large bowel can absorb up to 10 litres a day. If we are slow to pass our stool, it becomes progressively harder as more water is reabsorbed. The harder the poo, the more difficult and painful it is to pass. The hard poo can tear the bottom on the way out and it can bleed. This hurts intensely and children can get scared of pooing. Then they hold on. The more they hold on the harder the poo getsas more water is reabsorbed and a cycle of constipation begins. This can cycle can be hard to break and can take a long time. The frequency of passing poos is variable. A bowel action as infrequently as 4 times a week can be normal if there are no other problems.

Colon

1 Dr Kathy Lee, General Paediatrician Updated Jan 2015

Constipation Can Cause Problems

  • When a child has stool sitting in end part of the large bowel for longer than normal, the muscles of the bowel become stretched and weak.
  • The bowel regularly sends signals to the brain to tell us if the lower bowel is empty or full. When we get the signal that it is full, we arrange to go to the toilet at a convenient moment. If we hold on, or don’t properly empty the bowel, then the brain is constantly getting a signal that the bowel is full. Over time the brain learns to ignore the signal and not notice it at all. Then we don’t know when to go until it is too late resulting in accidents.
  • If there is a hold up of stool being past, the liquid stool from upstream in the bowel can leak out also causing soiling
  • Up to 85% of children with constipation also soil (leak stool out of the bottom) this is due to severe impaction. It is often confused by parents who think it means their child can’t be constipated.

What causes the hard poo?

There are a few reasons to cause hard poos. This can be:

  • Dehydration
  • From a fever, not drinking enough water or after gastroenteritis
  • Diet
  • Lack of fibre, high in processed foods, a change of diet (often related to travel) and dairy causes constipation in a small number of people
  • Reduced activity
  • Such as a long drive in the car and lying in hospital
  • Holding because
  • The toilets at school are dirty, the child would rather play than go when they really need to, other children look at them under the door when they go at school, they are afraid of it hurting
  • Poor bowel habits – see below
  • Some medication
  • Fear
  • Once the child learns that pooing hurts, they hold out of fear. This is a bad cycle.
  • Other Emotional Factors
  • Anger: Constipation in children that is hard to overcome is occasionally related to parental anger. The child learns that by holding on to their stool, they upset their parent. This can give the child a sense of power over the parent. They continue to hold on to wind the parent up. Breaking the pattern of allowing the child to wind the parent up is vital.
  • Anxiety Issues can also result in constipation. Allowing a child to be relaxed about passing bowel actions is vital. It is impossible to require a child to pass a bowel action. Doing so can cause performance anxiety and may make constipation worse.

Some Foods That Are Good For Constipation

Peas (raw or even frozen in a cup as a snack is great) beans, corn and other raw vegetables, lentils, fresh fruit such as apple with the peel on and apricots, baked beans on grainy bread toasted is an easy snack, prunes and other dried fruits, and popcorn in children > 4yo (choking risk in younger children).

Serious Causes Of Constipation Are Unusual

  • Infant formula is a recognised cause. You need to find the right formula for your child as no particular one is right for all.
  • Some children develop constipation from the introduction of solids. Usually this is related to the lack of fibreearly on.
  • Surgical causes - If constipation starts from birth, a surgical cause may present, but the vast majority of children with this problemcan’t pass a bowel action at all from birth.
  • Coeliac disease(gluten Intolerance) can cause constipation or diarrhoea.
  • Constipation may develop in someone who has hypothyroidism. This is very unusual in young children. It tends to occur in young women.
  • Lead poisoning is a rare cause.
  • Food allergies can cause constipation that is hard to treat. The child starts with diarrhoea that burns the bottom. They learn to hold and then develop constipation. This is quite uncommon. Foods that can cause this are dairy, soy, wheat, eggs, nuts and fish. They need to be excluded from the diet for 3-4 weeks to see a change. When they reintroduced and the constipation will return quickly. A dietician should be involved when a child has any food excluded long term to balance their diet.

Good Bowel Habit

A good bowel habit is essential to prevent and treat constipation.

  • When the child sits on the toilet, it should not be in an upright position like on a throne. They should lean forward with arms on the legs as if bearing down in labor. The child’s feet must be able to rest on a hard surface – the floor or a stool.
  • The easiest time to our bowel actions is about 15-20 minutes after having eaten. The body has a natural reflex that means that when food is put in our stomachs, everything moves along and then hopefully out. So sitting on the toilet for at least 3 minutes and preferably 5 minutes should ensure a bowel action most days.
  • The best time to pass bowel actions is after breakfast. For busy families, the morning may need to be rearranged so childrenget up and eat breakfast, go and get dressed and then sit on the toilet for 5 minutes.
  • You cannot make your child poo but you can require them to siteven if they don’t poo. Trying to make them poo is the fastest way to result in a child holding just to wind you up or in creating anxieties.
  • Privacy in the toilet for a child who is old enough to wipe themselves is important. Constipation can be monitored by looking for other signs such as soiling, leakage of Parachoc and abdominal pain.

Treating Constipation

Please use this in consultation with your doctor and if needed, paediatrician. It is not intended to replace seeing your doctor. There are four important phases to treating constipation.

Diagnosis: first is reviewing the causes and making sure there is no serious underlying issue. While this is very uncommon, it is important.

CleanOut: It is important at the start to clean out ALLretained stool. If this is not achieved, the rest will fail. By cleanout, what is meant is giving medication so that the stool is watery so no retained slightly hard stool is present. This is usually done via Movicol or Osmolax in children. See the Women’s and Children’s Hospital Paediatric Emergency Department brochure.

Maintenance:The aim of this phase is for the stretched muscles to recover and your child to learn to recognise the sensation of the bowel being empty and full. This will require good bowel habits to be established. Any fear of holding on should be overcome. Any holding on behaviour means at least another month of maintenance is required.

This phase should last at least 2-6 months for children with chronic constipation. During this time, medication is used to keep the stool like toothpaste. It should be easy for your child to go, but not without some effort. The two routinely used medications are Lactulose and parachoc. They are both stool softeners, meaning they help water to be kept in the bowel to keep the stool soft. They don’t stimulate the bowel and so don’t’ do the work of passing the bowel action for the child. For poor diet, use Fibresure if their diet cannot be changed. This should be done after consultation with a dietician to see if other options are available. Slowly add to the diet as bloating may occur.

Weaning Phase (Bowel Gym): If you require an unfit person to suddenly lift 100kg they won’t be able. But if the person goes to the gym and starts with 5kg and then gradually works out, increasing the weight they are lifting, they will gradually get to lift the 100kg. The same principle applies to the bowel. Once your child is maintaining toothpaste stool and has a good habit and knows when it is time to go to the toilet, the medication can gradually be weaned. This will gradually require the bowel muscles to do more work over time. How quickly you wean depends in part how long the child has been constipated and in part whether there are any set backs during the weaning process. Remember if any of the risk factors listed above occur, you may need to increase the medication again briefly.

The aim is to wean by 10% per fortnight. Sometimes you might not reduce at all and if all is going well wean more quickly. If you suddenly stop, it would be like expecting the unfit person to suddenly lift 100kg.

Abdominal Wall Strength

Another factor in constipation may be low abdominal wall strength. So many people sit and stand with a slouched posture. As a nation, we are less fit in general and less likely to have strong abdominal wall muscles. Some basic exercises to strengthen them will help. For example:

Leg Raises: are designed to tone your child's lower abdominal muscles. Have your child lie down on their back on a bench with their back flat. Then have them extend their legs out until they are parallel with the ground. Have them tighten her abdominal muscles and lift their legs up off the bench until they are at a 70 degree angle. Have them hold for several seconds before lowering their legs back down and not touch the ground. Repeat until fatigued.

However the best option is to get the exercises shown to your child by a physiotherapist.

Other Medication Options

Picolax

Dose

1–2 years ¼ sachet before 8a.m. then ¼ sachet 6–8 hours later

2–4 years ½ sachet before 8a.m. then ½ sachet 6–8 hours later

4–9 years 1 sachet before 8a.m. then ½ sachet 6–8 hours later

9–18 years 1 sachet before 8a.m. then 1 sachet 6–8 hours later

Acts within 3 hours of first dose. Low residue diet recommended on the day before and copious intake of water or other clear fluids recommended during treatmentCounselling: One sachet should be reconstituted with 150 mL (approx. half a glass) of cold water; Be warned that heat is generated during reconstitution and that the solution should be allowed to cool before drinking.

Nulax Fruit Laxative 250g. Contains Senna.Similar taste to dates and figs.

Adult dose 10g: Once daily 3 level 2.5ml medicinal measuring spoons.

Children 5g: half the adult dose.Do not administer to children under the age of 2 years.

If too firm, warm slightly and knead until pliable. Refrigerate after opening.

Laxettes

Laxettes contain Senna; recognised as one of the most popular and reliable natural laxatives. Available in both tablets and chocolates.

Laxettes Chocolate: are available in packs of 24 and 48 easy to consume squares.

Dosage: Adults and children over 12 years: 1 to 3 squares. Do not exceed 3 squares daily except on medical advice. Dose to be taken at bedtime.

Important: If symptoms persist, seek medical advice. Drink plenty of water. Increase fibre in diet. Prolonged use of laxatives is undesirable and may lead to dependence. Do not use when abdominal pain, nausea or vomiting are present, or if you develop diarrhoea. If you are pregnant or breast feeding, seek advice of a healthcare professional before taking this product.

Laxettes Tablets: are ideal if you prefer to take tablets rather than liquid or chocolate-based laxatives.

Dosage: Adults and children over 12 years: 1- 3 squares. Do not exceed 3 squares daily except on medical advice. Dose to be taken at bedtime.

Important:If symptoms persist, seek medical advice. Drink plenty of water. Increase fibre in diet. Do not use when abdominal pain, nausea or vomiting are present, or if you develop diarrhoea. If you are pregnant or breast feeding, seek advice of a healthcare professional before taking this product.

Warning:Laxettes should be used as a short term means of re-establishing normal bowel activity while you are simultaneously correcting dietary problems. They should not be used indefinitely or in excessive dosages. Prolonged use may lead to dependence

Osmolax: Should not be used as an alternative to Movicol for cleanouts. It is said to draw water in to the bowel and bulk the stool. It is difficult to wean the dose. However it can be good in the short term for after Movicol to establish a good bowel habit.

Fybogel (

Each dose of Fybogel granules should be stirred into a glass of water (at least 150ml) and taken as soon as the fizzing dies down. The medicine should preferably be taken after meals. It should not be taken shortly before going to bed.

Adults and children over 12 years of age should take the contents of one sachet dissolved in a glass of water morning and evening, after breakfast and evening meals.

Children aged 6 to 12 years should take half to one level 5ml spoonful of granules, depending on size and age, dissolved in a glass of water after breakfast and evening meals.

Children aged under six years should only be given this medicine on the advice of a doctor. They should be given half to one level 5ml spoonful of granules, depending on size and age, dissolved in a glass of water after breakfast and evening meals.
Metamucil Dosage
Adults and children over 12: Take/mix one dose with/in 240 mL of cool liquid at the first sign of irregularity. Can be taken up to three times daily if needed. Generally produces results in 12 to 72 hours.
Children: 6 to 12 years: Take 1/2 adult dose powder or wafers in/with 240 mL of cool liquid.
Children under 6 years: Consult a doctor.

1 Dr Kathy Lee, General Paediatrician Updated Jan 2015