Constipation in Children
Constipation is a very common problem for children. For most children, constipation means passing hard stools, with difficulty, less frequently than normal.
Your child's bowels - what is normal?
Parents often get very worried about their child's bowel habit. The main thing to realise is that every child is different. Babies will open their bowels anything from several times per day, to once every few days. The frequency of bowel movements is not particularly important. What is important is that the stools are soft and easily passed.
Breast-fed babies tend to pass runnier, mustard yellow-coloured stools. This is because breast milk is better digested than infant formula (bottle feeds). Newborn breast-fed babies may open their bowels with every feed. However, it is also normal for a breast-fed baby to go up to a week without a bowel movement. Bottle-fed babies often need to open their bowels daily, as the stools are bulkier.Baby's stools may vary in colour and consistency from day to day normally. Any prolonged change to harder, less frequent stools might mean constipation.
As babies are weaned to solid foods, their stools will change in colour and smell. The frequency may again change. Generally the stools become thicker, darker and a lot more smelly.
As your baby grows up, into a toddler and then a young child, you may see further changes in their stool frequency and consistency, often dependent on what they are eating.
Your child's bowels - what is abnormal?
There is great variation in a child's bowel habit, dependent on their age and what they are fed,it is a change in what is normal for your child, that suggests a problem. Anything from three times a day to once every other day is common and normal. Less often than every other day means that constipation is likely. However, it can still be normal if the stools are soft and well formed, and passed easily.
What is constipation?
Constipation in children or babies can mean any, or all, of the following:
Difficulty or straining when passing stools.
Pain when passing stools, sometimes with a tiny amount of blood in the nappy or on the toilet paper, due to a small tear in the skin of the anus.
Passing stools less often than normal. Generally, this is less than three complete (proper) stools per week.
Stools that are hard, and perhaps very large, or pellet-like and small.
Other symptoms of constipation:
Tummy ache (abdominal pain).
Behavioural changes, such as being more irritable or unhappy.
Fidgeting, restlessness and other signs that the child needs to go to the toilet.
Feeling sick (nausea).
Types of constipation in children and babies
Ideopathic i.e. unknown cause, it is the commonest cause.
Children become constipated for no known reason.Short bouts of constipation may settle quickly, often without the need for medical treatment.Long-term constipation. In about 1 in 3 children who become constipated, the problem becomes more long-term . This is also called chronic idiopathic constipation.
Secondary constipation i.e. due to an underlying disease or condition. This is uncommon
Some neurological conditions ,Hypothyroidism ,Cystic fibrosis,abnormal development of the bowel, such as Hirschsprung's disease(rare).
As a side-effect of certain medications that a child has to take for another condition.
Treatment may involve treating the underlying condition (if that is possible) in addition to tackling the constipation.
Worrying symptoms or signs that may indicate a secondary cause include the following.
Weight loss or failure to gain weight (thrive).
A swollen, stretched tummy.
A baby that does not pass its first stool (called meconium) within the first 48 hours of life.
Abnormalities of the anus - for example if it is closed over.
Neurological (nervous system) problems such as weak or paralysed legs.
Sores or ulcers near the anus.
Urinary symptoms - such as passing huge volumes of urine, urine that is very dark or painful urination with smelly urine.
Very pale-coloured stools (especially if the urine is very dark too).
What causes idiopathic constipation?
No known cause for the constipation. However, it is thought that various factors may contribute to constipation developing, or make it worse.
Not eating enough foods with fibre(roughage)
Not having enough to drink.
This means the child has the feeling of needing the toilet, but resists it. This is quite common. The longer the child holds on, the bigger the stool gets. Eventually the child has to go, but the large stool is more difficult to pass, and often more painful. This may lead to a bit of a vicious cycle where the child is even more reluctant to open his or her bowels the next time.
There are a number of reasons why children may hold on to stools:
A previous stool that they passed may have been a struggle or painful.
Their anus may be sore or have a crack (anal fissure) It is then painful to pass further stools.
They may have a dislike of unfamiliar or smelly toilets, such as at school or on holiday. The child may want to put things off until they get home.
Constipation problems may be made worse with upset due to change in surroundings or routine. Common examples is starting pre nursery. Potty training may be a factor if a child becomes scared of using the potty. Fears and phobias are usually the underlying reasons for these problems.
What is idiopathic constipation with impaction?
Impaction means that the bowel is, blocked by a large amount of hard stool. Seen in children between the ages of 2 and 4 years, but older or younger children can be affected.
Symptoms and features include:
Recurrent episodes when the child is uncomfortable or distressed trying to pass a stool.
The child soils their pants regularly with very soft faeces, or with faecal-stained mucus. This is often mistaken by parents as diarrhoea.
The child may also become irritable, not eat much, feel sick, have tummy pains from time to time, and may be generally out of sorts.
A doctor can often feel a backlog of hard, lumpy stools when he or she examines the child's abdomen.
What is the treatment of idiopathic constipation?
Idiopathic constipation that has lasted for more than a few days is usually treated with laxatives. Type and dosage may depend on factors such as the age of the child, severity of the constipation and the response to the treatment. Laxatives for children commonly come either as sachets or a powder that is made up into a drink, or as liquid/syrup.
The laxatives used for children are broadly divided into two types.
- Osmotic laxatives .Macrogols are a type of laxative that pulls fluid into the bowel, keeping the stools soft. This is mixed into water or juice to make a drink. Macrogols and a Lactulose are commonly used.
- Stimulant laxatives. These stimulatethe bowel to pass the stools out. There are several different types of stimulant laxative. Sodium picosulfate, bisacodyl, senna and docusate sodium are all examples. A stimulant laxative tends to be added in addition to a macrogol if it is not sufficient on its own.
Laxatives are normally continued for several weeks after the constipation has eased and a regular bowel habit has been established.,may be for several months. Do not stop the laxatives prescribed abruptly. Stopping laxatives abruptly might cause the constipation to quickly recur. Dose should be reduced gradually over a period of time depending on how the stools have become in their consistency and frequency. Some children may even require treatment with laxatives for several years.
Treatment of impaction - if needed
Higher doses of laxatives are needed initially to clear the large amount of faeces blocking the rectum. Secondly, laxatives are also usually needed for much longer, as maintenance treatment. The aim is to prevent a build-up of hard stools recurring again, which will prevent impaction returning.If laxatives are stopped too soon, a large stool is likely to recur .In rare instances, where treatment of impacted stools has failed, a child may be treated in hospital. In hospital, stronger medicines to empty the bowel, called enemas, can be given via the rectum. For very hard to treat cases, a child can have a general anaesthetic and the bowel can be cleared out manually by a surgeon.
How can constipation in children be prevented?
Eating foods with plenty of fibre and drinking plenty makes stools that are bulky, but soft and easy to pass out. Getting plenty of exercise is also thought to help.
If a bottle-fed baby has a tendency to become constipated you can try offering water between feeds. It is unusual for a breast-fed baby to become constipated. Older, weaned babies can be given diluted fruit juice .Pureed fruit and vegetables are the usual starting points for weaning, after baby rice, and these are good for preventing constipation.Encourage children to drink plenty. However, some children get into the habit of only drinking squash, fizzy drinks or milk to quench their thirst. These may fill them up, and make them less likely to eat proper meals with food that contains plenty of fibre. Try to limit these kinds of drinks. Give water as the main drink.
Some other tips which may help
Try to get children into a regular toilet habit. After breakfast, before school or nursery, is often best. Try to allow plenty of time so they don't feel rushed.
Some kind of reward system is sometimes useful in younger children prone to holding on to stools. You could give a small treat, or use stickers or star charts to reinforce the message. Praise your child for passing a stool in the potty or toilet, but do not punish accidents. It is easy to become frustrated with soiled pants or a child who refuses to pass a stool. Try to keep calm and not make a fuss over the toilet issue. If your child can see that you are stressed or upset, they will pick up on this feeling, and the toileting issue can become even more of a fraught battle. The aim is to be 'matter of fact' and relaxed about it.
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