Constipation in children

Constipation is a common problem in children of all ages. It can be defined as infrequent passage of stools and/or difficulty in passing hard and painful stools.

To better understand the meaning of an infrequent passage of stools, it is helpful to know normal bowel habits. What is considered to be normal bowel habits depends on the child’s age and their daily diet. In the first year of life, breastfed infants averagely have 2-3 soft bowel movements per day. There are some breastfed infants who pass stools after every feed, and some who have bowel movements only once a week. It is rare to find constipation among fully breastfed infants. Formula-fed infants have bowel movements 1-3 times a day although sometimes this may depend on which formula is given. By 2 years of age, a child typically has 1-2 formed firm stools every day, and by 4 years old, they usually open their bowels once every 1-2 days.

A child who has constipation has stools that are hard and lumpy or pellet-shaped. It may be painful causing them to cry and strain during defecation. As a result of the pain and discomfort, many children tend to develop unusual habits including arching their back, crossing their legs, tightening their buttocks, squatting, or other unusual positions in an effort to avoid bowel movements. As the urge to have bowel movements comes and goes, the child will be shifting constantly from happily playing to sudden “attacks” of pain. Some children will hide in a corner and cry during such periods of pain.

After a painful episode, sometimes children may develop a small tear at the anus called an anal fissure, leading to further withholding of stools. This is a vicious cycle where withholding bowel movement causes larger and harder stools resulting in worsening anal fissures.

Most children with constipation do not have any medical problem causing the symptoms and this condition is termed as functional constipation. Constipation is more likely in children who lack dietary fibre and fluids, and who lead sedentary lifestyles. Occasionally, changes in the surrounding environment such as being at school or travelling may cause the child to delay their bowel movement as they are not comfortable at the unfamiliar place. Children who have an allergy to cow’s milk or dairy products may also have constipation, although it is more common for them to develop diarrhoea.

Less than 5 percent of children with constipation are caused by medical conditions. Some of the possible medical conditions include hypothyroidism (low thyroid level), hypercalcaemia (high calcium level), Hirschsprung disease (abnormal nerve development in the colon), abnormal development of the anus, and problems with absorbing nutrients, abnormalities of the spinal cord, and certain types of medications.

Some home remedies may be tried first at home if a child has constipation.

Ensuring a high fibre diet

A diet rich in fibre will help produce softer and more formed stools. Foods such as fruits, vegetables, and wholegrain cereal and bread are good sources of dietary fibre. At least two servings of vegetables and one serving of fruits every day is a sufficient amount. Fruit juices that include prune, apple, and pear are tasty and easy to consume and can be served 2-3 times a week.

Fibre supplements are available in several forms for some children who may be picky with food.

Adequate fluid intake

A child of 1 year old and above should have at least 1 litre of fluids per day.

Promote physical activity

Regular physical activity helps to stimulate bowel movement.

Healthy toilet habits

Establishing a toilet routine may be helpful. Set aside a regular time after a meal each day for the child to sit on the toilet for 5 minutes. A footstool to support their feet with their knees slightly higher than their hips can help to relax the bowels.

Praising the child for their effort is beneficial even if they did not have any bowel movement. Remind the child not to withhold their urge especially when they are engrossed in their play.

What about probiotics?

The role of probiotics in managing constipation is still being studied. Due to the many different probiotic strains and their characteristics, as well as the uncertainty of the most suitable and effective dose, there is still insufficient evidence to routinely recommend probiotics in the treatment or prevention of constipation. If home treatment had not been successful in treating the child’s constipation, it will be helpful to arrange a visit to the doctor.

Treatment of constipation involves two steps- disimpaction (“clean out”) followed by maintenance therapy.

Disimpaction

Especially for children with chronic constipation, often the first important step is to remove the impacted stools in the bowel. The treatment may include laxative medications taken by mouth such as lactulose or macrogol, and sometimes rectal suppositories. Oral laxatives are less distressing for children. It can take up to a week to achieve disimpaction and so it is often helpful for school-aged children to take a school break for a few days.

Maintenance

After achieving disimpaction, maintenance therapy is initiated. The aim is to have soft and spontaneous bowel movements on most days of the week. Regular laxatives are usually needed for several months to avoid the recurrence of constipation from prematurely stopping medications. The laxatives are then titrated off gradually as opposed to sudden cessation to ensure treatment success.

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Dr Yeap is a paediatrician attached to KPJ Sentosa KL. Through his articles, he aims to help increase public awareness of the common issues associated with children’s health.

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