Constipation in children
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Constipation is the state in
which bowel movements are infrequent and the stool is hard and difficult to
pass.
The
effects are purely local in the lower bowel. These local effects may eventually
lead to serious disturbance.
The
younger the child, the more likely it is that the problem is due to an organic
cause.
It
is important to exclude Hirschprung’s disease. In this condition a segment of
the bowel does not relax to allow the passage of stools because the nerve supply
is absent.
he commonest cause of abnormal
infrequent defecation in infancy is underfeeding.
The
treatment is the treatment of the cause.
A distinction must be made between
soiling and encopresis.
Soiling is the involuntary
passage of small amounts of stool, and results from chronic constipation.
Encopresis is the passage of normal
stools at inappropriate occasions. It generally results from inadequate training
or severe emotional disorder.
What is
constipation?
Constipation is the state in which bowel movements are infrequent and
the stool is hard and difficult to pass. The average baby passes three to six
stools per day in the neo-natal period, one to two stools per day at one year
and one per day or every other day in the pre-school years. Nevertheless, normal
bowel frequency varies widely: some breastfed infants have a bowel action of
normal consistency only once every three or four days and older children may be
equally infrequent, yet pass normal stools.
What are
the harmful effects of infrequent defecation? The myth of serious toxic effects
caused by un-passed stools has long been discounted, though it derived from what
the medical profession taught generations ago. The effects are purely local in
the lower bowel. Nevertheless, the local effects, minor in their beginnings, may
eventually lead to serious disturbance in some children.
Constipation of
recent onset
Absence of defecation may be due to acute intestinal obstruction, in
which case the presenting features are likely to be abdominal pain, vomiting and
shock. This article does not discuss the causes of acute obstruction, but will
focus on the mundane and less glamorous chronic variety.
Constipation in
infancy
Although the vast majority of children presenting with constipation
have no serious underlying pathology, the younger the child, the more likely it
is that the problem is due to an organic cause. It is particularly important to
exclude Hirschsprung’s disease.
Some organic causes of constipation
Hirschprung’s
Disease
Anorectal anomalies
Cystic
fibrosis
Metabolic
and endocrine:
Hypothyroidism
Hypercalcaemia
Hypokalaemia
Renal
failure
Toxic:
Lead poisoning
Spinal
cord lesion
Cerebral
palsy
Hirschsprung’s disease
In this condition a segment of the bowel, usually the recto-sigmoid
junction, has no nerve supply, and does not relax to allow the passage of
stools. The condition is present at birth.
In the
early months, diarrhoea or infrequent passage of stools or even complete
obstruction may occur. The child may be under-sized and the appetite poor.
Abdominal distension is often seen. On rectal examination there may be no
particular resistance to the examining finger and the rectum contains no faeces.
Soiling is extremely rare.
A Barium
enema shows a narrow segment usually in the rectum or sigmoid colon but
occasionally higher up in the intestine. Removal of the abnormal segment by an
abdomino-perineal operation gives excellent results.
Notes on causes of constipation in infancy
The
commonest cause of abnormal infrequent defecation in infancy is underfeeding.
Underfeeding, whether on breast or bottle, in the first month or two of life may
lead to the passage of small, semi-liquid, dark-green stools.
Constipation
may result from insufficient fluid intake, especially during a feverish illness,
or
else to a change in feed or routine. Casein-containing milk formulae are more
likely to constipate than the low-casein varieties.
Nevertheless, hard stools may be
passed by infants who are well-nourished and evidently getting all the food they
need. In these infants the process of absorption of water may be unduly active.
Straining to pass a hard
stool may result in abrasion to the anus – an acute fissure-in-ano - and the
stool will then often show a small streak of fresh blood. The pain on defecation
results in further retention. If the fissure is not recognised and treated, it
can become chronic. Severe faecal loading in the older child often has its
origin in such an incident in infancy.
How is it treated?
The treatment of infrequent defecation in infancy is the treatment of
the cause.
The
breastfeeding infant with an infrequent bowel pattern needs no treatment.
Underfeeding
should be rectified.
In infants under four months on
formula feeds, an increase in fluids between feeds is often all that is
required.
Over four months, the introduction of
cereal and fibre in the form of sieved vegetables and unsweetened stewed fruits
is beneficial.
A fissure-in-ano should be treated by
the application of an ointment containing a topical anaesthetic, such as
lignocane, to the anus. It should also be inserted gently into the anal canal
with the little finger. This should be done three times a day, and if possible,
just before a stool is passed.
A
stool softener such as lactulose or sorbitol is also helpful.
If
the stools remain hard and infrequent, then a safe and helpful measure is the
use of senna tablets or granules at night for a limited period.
Avoid
all preparations containing phenolphthalein, castor oil or cascara.
Phenolphthalein and cascara can damage the colon and induce dependency. Castor
oil contains ricin, which is carcinogenic. Medicinal paraffin affects absorption
of fat-soluble vitamins.
Constipation in
older children
The origins of constipation in older children are often difficult to
pinpoint and several factors may initially have been involved:
Loss of appetite during an acute
illness
The prescription of constipating
medications for diarrhoea
Pain from an anal fissure
A
stressful life event
Having
to rise early and travel long distances to school in the morning
The
need to use a cold and often unhygienic outside toilet; or filthy toilet
facilities at school
Over-rigid
management by parents determined to see their child toilet-trained at an early
age.
Retained
faeces become hard and painful to expel and as they build up, the rectum
gradually becomes distended, reducing rectal sensation and thus diminishing the
urge to defecate. There is frequently over-flow soiling caused by fluid stool
and mucus passing around the hard faeces and staining the child’s underwear.
The
child may be smelly and become the butt of jokes at school. This can have
profound effects on well-being and self-esteem. Parents or teachers may adopt a
punitive approach towards the child and compound an already unfortunate
situation.
A
special problem is that of chronic constipation in children with mental handicap
and neurological disabilities such as cerebral palsy or spinal cord
abnormalities.
Chronic
constipation should be suspected when abdominal and rectal examinations show
palpable faeces, confirmed by straight abdominal radiographs showing faecal
content that may fill the entire colon. Gross distension of the bowel is not
commonly seen.
Children
with chronic faecal loading are often misdiagnosed as having chronic diarrhoea,
non-specific abdominal pain or psychological encopresis. It has also been shown
that constipation can cause reversible urinary tract abnormalities that may
result in urinary tract infection and incontinence.
How is it treated?
Clearing the bowel:
The
colon and rectum must be evacuated using repeated Microlax® (5ml) or Fleet®
(62ml) enemas.
In advanced cases the administration
by mouth of large volumes of a balanced electrolyte polyethylene glycol solution
such as Golytely® is helpful.
The
diet should be carefully adjusted to include more fibre– bran containing
cereals, brown or whole-wheat bread, vegetables, and more fruit and fluid
intake.
In
addition, bulk laxatives should be given – such as Metamucil® (psyllium), or
Fibogel® (ispaghula) - and continued for several months.
If
this form of laxative is insufficient, it should be complemented with a stool
softener (lactulose) or bowel stimulant (senna tablets or granules, one to three
tablets or teaspoons at night for three to six weeks).
Encouraging
a regular bowel habit:
A child should be encouraged to use the toilet at a fixed time every day and
rewarded for doing so (behaviour modification). Punitive measures and harsh
discipline are often at the root of the problem and parents need to be advised
about this.
Faecal soiling
and encopresis
As distinct from the faecal soiling or overflow incontinence in
chronically constipated children just described, encopresis is the passage of
stools at inappropriate occasions. Encopresis generally results from inadequate
training or severe emotional disorder.
Inadequate training
Some children will have had continuous encopresis from infancy. The
family is generally disorganised and chaotic, the caregiver will have made no
serious attempt to train the child and the care may be cold and uninterested.
These children respond well to a proper training programme, warmth and
encouragement.
Underlying emotional disturbance
Encopresis can reflect a poor parent-child relationship, often of
long standing, and often associated with other psychiatric problems. This
symptom nearly always indicates that the child and parents need expert
psychological assessment and help without delay. This will include behavioural
(star chart) and individual psychotherapy, and parental counselling and family
therapy to modify attitudes and hostile interactions.
Lastly,
it should be borne in mind that faecal soiling may occasionally be a
manifestation of sexual abuse.
Laxatives for
use in children
Bulk laxatives
Bran and other vegetable fibres are best
Metamucil® (psyllium), ½ to 1 sachet daily
Fybogel® (ispaghula), ½ to 1 sachet daily
Contact laxatives
Senokot® (senna), 1 to 3 tabs at night
Osmotically active laxatives
Magnesium hydroxide, 2.5 to 5.0 ml daily (suitable for young infants)
Duphalac® (lactulose), 2.5 to 15 ml daily
Golyteley® (balanced electrolyte polyethylene glycol solution), 1 sachet in 1
litre of water: 20-25 ml/kg/hour
Avoid
all preparations containing phenolphthalein, castor oil or cascara.
