Constipation In Children - Causes, Prevention, and Management

Constipation in children is a common disorder. About 10-30% of patients attending pediatric gastroenterology OPD (Out Patient Department) have the disorder of fecal elimination.

As we know constipation is a well identified and easily noticebale disorder in adults. But it is not so easy to identify in children due to their infrequent/irregular bowel movements. It is more difficult to identify in early phase in the present scenario because most of the parents are working and someone else takes care of their children. If this problem does not get attention at the earlier stages, it can lead to psychosocial disturbances in the child, decreased school performance and growth failure. So, a simple disorder like this can lead to a devastating condition.

Normal stool frequency in children is 4-5 times a day in infancy and 1-2 times a day in toddlers.

Simple definition for constipation is "Frequency of bowel movements less than 2 per week or passing of hard stools requiring excessive straining with or without presence of blood in stool".

Causes

Causes for constipation in infants include :

• Congenital malformation.
• Endocrine disorders.
• Dietary factors.

Causes for constipation in elder age group include :

• Anal fissure.
• Functional constipation.
• Dietary factors.
• Psychosocial factors.
• Rectal ulcer.

Clinical Features

Passing of hard pellet like stool requiring excessive straining with or without decreased frequency of stool or presence of blood. Some children present with nonspecific abdominal pain. These children may withhold stool if there is pain experience due to anal fissure or hard stool. This creates a vicious cycle. These children may pass hard stools that block the toilet. These children may have retentive posturing and may pass stool behind the door/sofa/curtain. If not diagnosed earlier this can lead to decreased appetite and decreased food intake subsequently anemia and growth failure. Untreated children may present with acute gastrointestinal obstruction in emergency.

Methods of Investigation

• A proper history and evaluation of the onset of the signs and symptoms is the key to identify the problem.

• Investigation depends on the age, duration and suspected etiology in the individual child.

• It includes CBC (Complete Blood Count), biochemical profile, ultrasound abdomen, TFT (Thyroid Function Tests), barium enema study and coeliac serology in suspected cases.

Management

• Management of local cause like anal fissure is done by sitz bath (sitting in warm water such that only your hips and buttocks are in water) and with local analgesics and short term laxatives.

• Management of psychosocial issues.

• Diet modification - dietary management in the form of high fibre diet and adequate amount of water.

• Laxative - use of laxative depends on the duration of the illness.

In acute cases of constipation (2 weeks to 2 months duration), paediatricians give short term laxative (lactulose for 2 weeks) to relieve symptoms and then dietary management has to be continued.

In chronic cases of constipation (more than 2 months) we need to identify if there is impaction of stool (fecal impaction is hard stool stuck in the rectum due to chronic constipation). If there is no impaction, use Polyethylene glycol (PEG) as osmotic laxative for atleast 6 months duration, titration of dose is required during follow up. If fecal matter is impacted, first we need to do disimpaction by saline enema then continue polyethylene glycol for at least 6 months.

Along with management of constipation it is necessary to manage nutritional issues with multivitamin supplement.

How to Prevent?

To some extent it is preventable by good toilet training started at the age of 12 to 15 months and by regularising the bowel movements. Toilet trainingis the art of teaching the child to make a routine defecation. Make sure the child sits in the toilet for 10 to 15 minutes daily during a fixed time preferably in the morning after having breakfast. Because eating something leads to an urge to defecate. So one can take advantage of these reflex movements. Use a single word to indicate defecation, otherwise your child may get confused what to do and actually this is also a cause for constipation in children belonging to multilingual families.

Other preventive method is dietary management in the form of adequate fibre diet.