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CONSTIPATION IN CHILDREN … (May, 2006)

Constipation is a very common ailment in the society today. Every person has suffered from it at some time or the other. Our rapidly changing living standards, shifting onto more refined and processed foods and poor physical activity are all to blame. However, constipation in children is a special problem. This discusses some of these issues about constipation in children.

What is a “normal” bowel habit?
A normal bowel habit is one where the process of stooling is painless and easy. The stool itself is not very hard and “pebbly”. However, this varies widely. A new born child, who is breast feeding , may pass stool anywhere between 8-12 times a day to once every 3-4 days. Again, as far as the process is painless, it is acceptable as normal. Older children, who are on regular diets and foods, should stool at least once every 2-3 days- though most would go daily. Irrespective of the frequency, if stooling is painful and causing severe discomfort to the child, it is abnormal and will need medical attention.

Is constipation common in children?
Yes, constipation is very common and most children will have a few episodes of it. However, in a majority it is occasional and a rapid recovery is the norm. Such episodes may follow a stressful event such as a respiratory infection, a family outing, a new school etc.When the episodes persist or recur frequently, it needs to be evaluated.

How does normal defecation occur?
The food that we eat is the major source of stool content. The lining of the bowel is frequently shed and this along with some mucus accounts for the remaining content. As food passes down the intestine, enzymes digest (break it down into it’s basic units) it and these nutrients are absorbed. This activity is predominantly in the small intestine. The digested food then enters the large intestine. By this time, the contents are roughage(fibre) and water. This water is gradually absorbed as food is transported down the large intestine. The feacal matter is now held in the last part of the large intestine, the rectum, until the bowel is opened and the stool is passed.

This entire process is a coordinated and incredibly complex activity involving the intestines and nerves. Special nerves within the intestine regulate this whole sequence. Opening of the bowel to pass stool is again a complex activity requiring an elaborate coordinated effort from the rectum, the anus and the spinchters(the muscles that provide control).

When does a baby pass stool for the first time?
A baby usually passes stool for the first time within the first 12-24 hours of birth. If the baby has not passed stool by 48 hours of birth, it needs medical attention. The initial stool will be dark green to black in colour (called meconium) and this will turn to yellow as the baby begins to feed. Usually, by 4-5 days the stool is a golden yellow colour.

What if the baby has not passed stool for more than 48 hours?

It is essential that the child be reviewed by a paediatric surgeon. He / she will examine the baby and consider the following :
is there an anus? If not, it will require emergency surgery.
Is the anus in the normal place or does it appear somewhere else? If the site is abnormal, again this may need surgery.
Does the child appear distressed?
Is the abdomen distended?
If there is a normal anus, the doctor may pass a small tube or a suppository to try to stimulate defecation.

By these simple tests and examination, the doctor will be able to decide if there is a problem that needs investigation and treatment / surgery. He/she will then guide the baby along further tests and treatment.

My baby is breast fed. He is passing stool with every feed-the stool is occasionally runny. Is there a problem?
No. Breast fed babies have a wide range of frequency of stooling. This could be as frequent as after every feed or as less frequent as once every 2-3 days. This is not a problem as far as the baby does not have pain while passing stool and is growing well.

My baby is on formula feeds. Can it cause constipation?
Yes, formula fed babies are at a slightly greater risk of constipation. It is very important to reconstitute the formula exactly as per the recommendations of the manufacturer. Adding too much formula or too little water can make the feed very thick and can result in constipation.

When will my baby be potty trained?
Left to himself the baby will gain night time control for stool by about a year of age. The day time control (potty trained) can take anywhere upto 11/2 to 21/2 years of age. There is an overwhelming zeal in young mothers to potty-train their children. Some often start as early as after the first birthday. This is understandable in the background of working mothers, early start to schooling and crèche based care. However, the baby’s system is really not mature enough to carry out this complex task and such premature efforts are usually doomed to failure. This often leads to stress and tension both for the parents and the baby. It is useful to remember that achievement of control is a natural phenomenon and will happen in due course of time. As with anything else, some kids are faster and some just take a little more time.

So, is there nothing that the parents can do?
That is not true. The parents can act as facilitators for habit formation. Gradually familiarise the child with his potty and encourage them to sit on it-initially with his clothes on. Gradually move to sitting them on the seat at a fixed time every day-preferably in the morning after their milk. Keep them on the seat for 10-15 minutes, maybe read them a story or sing songs!. Reward them if they ‘perform’. There really is no need to coerce a small child into behaving like an adult with his potty routine. A majority of children will master the ‘art’ with time-patience is the key here!

Why does a child get constipated?
Constipation is commonly seen during the preschool age groups. It may begin around the later half of the first year and coincides with weaning. This is the most critical time. As the stool gets firmer because of a changing diet, it is important that the child passes stool regularly. Failure to do this will make the stool harder (as the rectum and large intestine will progressively absorb more and more water). Eventually when the child passes this hard stool, it causes pain and spasm of the sphincters. This dissuades the child from stooling and the child then tries to postpone the act. This results in the stool getting more hard and the vicious cycle is initiated and perpetuated. This is called habitual constipation and is by far the commonest. The need for attention during this period cannot be over emphasised. At this stage the problem is easily treated, with least interruption to the child’s development. Delay can result in a very protracted, unpleasant and difficult course for this child.

Occasionally, there might be disorders of the intestine that can result in constipation. A condition called Hirschsprung’s Disease is the common in this group.

What is Hirschsprung’s Disease?
Hirschsprung’s disease (HD) is a condition wherein, the special nerves in the intestine that help propel stool, are absent. This results in a segment of intestine-usually nearest to the anus-being incapable to propelling stool. HD can present itself in many ways:
a) in the newborn-as a failure to pass stool within the first 48 hours of life
b) in the first year-as an emergency with obstruction to the intestine-marked by yellow vomits, abdominal distension and constipation
c) in the older chilled- as constipation

The problem is diagnosed on the basis of a rectal biopsy, which actually looks for these special nerves. Special x-rays may be performed. The treatment is surgical. An operation will be required. This will aim to remove the segment of intestine (usually rectum) and join healthy intestine to the anus. Results of treatment are good.

How is a child with habitual constipation treated?
As the name suggests, habit formation becomes the key. Treatment is by a combination of:
a) diet modification-to exclude biscuits, chocolates, excess milk and milk derivatives such as cheese and to include greens, vegetables, fruits etc.
b) plenty of fluids
c) laxatives-milder laxatives are often used to keep the stool soft and allow time for the child to have painless stooling and regain confidence and also develop a regular pattern of stooling.
d) Habit formation and retraining-as mentioned previously, encouraging using of a potty at a fixed time daily

These strategies work in a majority of children and only a very small proportion will require anything more. In resistant cases, it is essential to rule out disorders such as HD. These are a difficult group to treat and require a practical, patient and encouraging approach

So what’s the message here?
1.Do not be obsessive about potty training-all children will eventually master the ‘art’
2.A healthy, wholesome diet is critical. Plenty of fluids too is essential.
3.Constipation in children is common.
4.Most episodes are self-limiting and do not need any special care.
5.Few children can develop habitual constipation and this needs special attention.
6.Disorders like Hirschsprung’s disease are rare, but are easily diagnosed and treated.
7.Do not self medicate. If in doubt, consult a paediatrician/paediatric surgeon.
8. Laxatives in children are to be given only under medical supervision-abuse can lead to serious and often irreversible consequences.

Dr R.Sanjay Rao, MBBS, MS. DNB(Gen. Surg.), Mch (Paed. Surg.), DNB (Paed. Surg.) FRCS (Paed. Surg.).

Consultant Paediatric Surgeon, Narayana Hridayalaya, Bangalore.
Email: sanjayrao98@hotmail.com




 

Updated on 01.05.2006.
 

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