If a child passes less than 3 stools per week and there is associated difficulty in passing them, then it is called constipation. Some normal breastfed babies pass soft stool on the 2nd or 3rd day without difficulty. This is not constipation because there is no associated difficulty in passing stool. A child may pass stool daily but if there is accompanying difficulty in passing it (due to hard consistency or size) then also it is called constipation.
Initial constipation may be due to:
o Change in routine diet
o Various illnesses
o Stressful events
o Unavailability of toilets (travel etc.)
o Child's busy schedule (morning school)
Leads to large, hard stools
These cause pain during defecation
May lead to fissures or cuts near anus
More pain during every subsequent passage of stool
Stool-withholding due to fear of pain
Stools become drier, firmer, and larger
Further increase in constipation
Most of the cases of constipation (almost 95%) are precipitated and perpetuated by these events. Other causes of constipation in children are:
o Spinal cord lesions
o Cerebral palsy
o Congenital megacolon (Hirschsprung's disease)
o Anal stenosis
o Hypothyrodism
o Diabetes insipidus
o Hypercalcemia
o Codeine containing cough syrups
o Anti epileptic drugs
o Anti psychotic drugs
Once the viscous cycle of constipation - painful defecation - stool withholding - constipation sets in the child refuses to sit on the toilet, rises on his toes, holds his legs and buttocks stiffly and often rocks back and forth, holds on to a furniture, screams, turns red until the stool is passed. With time, such withholding behaviour becomes an automatic reaction.
MANAGEMENT:
Most children with constipation will benefit if proper treatment plan is implemented under the guidance of a Paediatrician with active involvement of parents.
A. Disimpaction (Clearing of retained stools).
In a child having constipation a hard mass may be felt in the lower abdomen due to impaction of fecal matter (stool). Sometimes multiple, small, hard, masses may be present. The first thing to do in such cases is to disimpact (remove) the retained stool.
In an infant glycerine suppository (a medical preparation which melts in the rectum) is used for disimpaction. This is pushed in after lubricating the anus. It melts inside and facilitates the passage of impacted stools. Bisacodyl suppository, 5 mg for under-twos and 10 mg for children over 2, is available in the market (Junifree, Dulcolax) and in quite effective. Enemas and lavage solutions should be avoided in infants.
In older children Polyethyleneglycol (PEG) solution is given orally or by naso-gastric tube (25ml/kg/hour) till the imparted stool is cleared. As the amount of solution is large, Reglan or Perinorm is given 15 to 30 minutes prior to giving PEG solution to reduce nausea and vomiting.
Another approach is to give Phosphate enema (proctoclysis) to disimpact the stools. Some doctors recommend normal saline enema for this purpose, but our experience is that phosphate enema (available as Proctoclyss) works better.
Once the impacted stools have been cleared, maintenance therapy should be initiated to prevent re-accumulation. This is done by the use of laxatives, toilet training and dietary modification.
B. Laxatives.
The commonly used laxatives in children are:
1. Lactulose
2. Sorbitol
3. Milk of magnesia (magnesium hydroxide)
4. Mineral oil (castor oil)
All of these are equally effective and are given in a dose of 1-3 ml/kg/day. Mineral oil and milk of magnesia are not palatable.
Lactulose is the most commonly used laxative but is expensive. Various market preparations (Duphalac, Laxose, MT - Lac) cost is the region of Rs.100/- for a bottle of 100 ml, which lasts for roughly 10 days.
The most important thing to remember regarding the use of laxatives is that they need to be continued for prolonged periods (sometimes several months). An early stoppage of laxatives invariably leads to recurrence of constipation.
C. Toilet Training.
Too early and too strict toilet training is detrimental to the child. The ideal age to impart toilet training is 2 years. Initially the child should be encouraged to sit on the toilet for 5 to 10 minutes, 3 to 4 times a day. Gradually the habit of going to toilet once daily in the morning can be developed.
Parents should neither threaten, nor punish the child for not going to toilet at the appointed hour. This can make the child tense or stubborn. In both cases the problem of constipation will worsen. Instead the parents should follow a reward system. The child should be rewarded for regular sitting on the toilet. This will act as a positive reinforcement for the child.
Older children with constipation should be encouraged to maintain a daily record of bowel movements, pain or discomfort, consistency of stool and the laxative dose. This helps to monitor compliance and to make appropriate adjustments in the treatment program.
D. Dietary Changes.
Most children with constipation consume a low fiber diet. Many of them are predominantly milk fed. Foods low in roughage (fiber) are - meat, gelatin, white bread, starches, potatoes, rice, macaroni, noodles, ice cream, cheese and of course milk.
The daily requirement of fiber is: Age + 5 = grams/day. For a five year old child it will be 5 + 5 = 10 grams/day. The fiber content of the diet can be increased by giving fruits like apples, pears, prunes and plums. Raw, leafy vegetables should be introduced. Figs, raisins, apricots contain lot of fiber. Peas, beans, sprouts, whole-wheat flour chapattis, should be added to the diet. These children should be encouraged to drink lot of fluids.
Constipation often can be a difficult problem to tackle, because instituting dietary change in children is easier said than done. On top of it parents are liable to stop the prescribed laxatives early due to the fear of habit formation. The treating doctor must allay parents' fear and also involve a dietician wherever necessary.