Frequency of bowel movements in infants and children vary. Some have bowel movements daily, while others go every several days. Infatnts have a average of 4 stools per day during the first week. By 2 years average is 1.7 stools per day and at age 4 years 1.2 stools per day. Some infants do not have bowel actions for several days.
Infrequent bowel movements alone does not imply constipation. Changes in the child's usual pattern of bowel movements, so that they occur less frequently and become associated with pain and straining may indicate constipation. Usually the stools are hard and dry. It is rare for there to be a disease process that is causing the constipation, usually there is a simple reason but the treatment can be difficult. How does it occur? During a certain period of time the faeces will become hard and slow the progress along the bowel. This can occur if there is a brief diet change or if there is a small period of mild dehydration that can occur with a cold. This then results in a painful bowel action that results in the child resisting the urge to go. This will result in a worsening of the condition and you suddenly have a vicious circle develop. So, constipation is caused by painful bowel movements, which result in voluntary withholding of faeces to avoid unpleasant defecation.
When these children get the urge to defecate, they may stiffen their bodies, cross their legs, tighten their gluteal muscles, walk on tiptoes, or hold on to furniture. They often are flushed. Some squat or hide in certain areas of the house. Such behaviour often is misinterpreted by parents as an effort to push and pass stool.
Other causes can include toileting issues. Sometimes overenthusiastic (usually Fathers) can cause toileting to be a negative experience and this can be the main cause of constipation. The severity ranges from a brief period constipation through to the difficult to manage encopresis.
Short term constipation In this instance the child will manage to pass the painful faeces and his bowel will return to normal. Sometimes this may require the help of an enema or suppository. This is quite common and is generally of no significance if an eye is kept on the diet.
Infants with Constipation Constipation in infants is common. This can be due to hot weather, using too much powder in preparing formula and early introduction of cows milk. A baby may be given 15- 30mls of warm water or cool boiled water between milk feeds.
Prune juice Infants do well with this. Cover six seedless prunes with water and bring to the boil. Simmer gently until a syrup has developed. Strain to remove lumps and store in a sterilised container in the fridge and use within 2 days. Give one teaspoon each morning. Pureed prunes may be offered to infants over 6 months.
Chronic or long term constipation If the build up of faeces remains then this sets in motion a chain of events that needs to be broken to resolve the constipation. The child will feel the urge to go to the toilet but 'straining' causes considerable pain and so s/he stops straining - withholding -(because it hurts) and so the urge to go will slowly ease. Later on in the day there will be another urge to go and s/he will remember the pain and so therefore consciously stops the urge. This results in a build up of faeces in the large bowel and this will become even harder and a viscous cycle is set in place. The build up of faeces will cause distension in the large intestine - similar to a balloon after it has been blown up a few times. At that point there is often the passage of small pellets or even overflow diarrhoea. The original cause of the constipation has resolved but this doesn't matter while the cycle is set in place. The child will be irritable, complain of pain and lose his or her appetite. Often the parent will notice a 'constipation' dance where the child is on tiptoes tightly clenching his buttocks and moving from foot to foot.
Encopresis This is where there is excessive soiling. Soiling is where there is significant amounts of faeces left in the underwear. This is often a school aged child and these children have lost the sensation of rectal fullness. This is usually due to long term untreated constipation. Some children will hide their underwear and in the older child this can cause significant problems with self esteem and school function. This needs to be addressed as soon as diagnosed and occasionally involves hospitalisation and bowel retraining under the care of an paediatrician.
Management The principle behind treatment is to break the cycle so that bowel actions are a comfortable painfree experience so the child does not 'hold it in'. This involves three phases.
Cleanout phase - where the build up is flushed out. This usually involves oral laxatives at high doses. Occasionally in some toddlers and those with significant encopresis this phase may involve enemas or suppositories.
Maintenance phase - where the large intestine is allowed to return to its original tone and shape.
Weaning phase - where slowly diet and other factors slowly take over the role of medications.
The length of each phase depends a great deal on how long the child has been constipated for. A rule of thumb is that it will take half as long as the problem. So if the problem has been there for 6 months it will take 3 months to treat. Laxatives and diet are the cornerstones of treatment.
Facts about laxatives
• They are all safe if taken as directed • They will not result in a 'lazy' bowel • They will not work if the diet is not adequate • They do not cause malnutrition. • They are a short term solution - but this may be 6 months or more.
Dietary Measures: It is essential that the child's diet and eating habits be reviewed. Correcting problem areas and providing a diet that is high in fibre will help to prevent recurrences of constipation Dietary fibre is a food component that is neither digested nor absorbed by the body. This undigested material may itself absorb water like a sponge resulting in the formation of larger, softer stools, which are more easily moved through the intestines and then passed.
Obviously, the child's age will influence what can be included in the diet. Diet recommendations for a child (who chews well):
The following foods should be included in each of the child's meals daily:
No food needs to be completely excluded from the diet, but it will be helpful to: - avoid excessive intake of cow's milk and other dairy products such as cheese and decrease the amount of high sugar, processed and junk foods consumed. The following is a suprising list of foods that have minimal fibre.
Rice
Bananas
Rice Cereals
Lentils or baked beans
Peanut butter
White Bread
Infant recommendations
avoid starting solid foods too early.
Babies on solid foods should have apricots, prunes, plums, peaches, spinach, beans; decrease the amount of bananas and apple sauce
give 1-2 ounces of 1/2 strength prune juice once or twice daily until stools are soft.
iron enriched formulas do not cause constipation
avoid frequent formula changes because it often leads to constipation
expect some temporary constipation when you transition from formula to cow's milk
Increase Water/juice intake Giving your child extra fluids will help keep the stool soft. Fluids to increase are water and fruit juice. A child should have 4 to 6 full glasses of fluid per day if possible.
Stool Witholding Behaviour Sometimes toddlers and preschoolers will seemingly purposefully not pass stool. This can occur under several situations.
Fear of passing stool - either because of pain or because of negative experiences - 'angry father syndrome'. These toddlers will often disappear to fill their pants in another room and will deny passing bowel actions.
Refuse to pass stool - as this exerts some control over their parents. There is a witholding of parenteral reward. Won't do can't do.
If constipation occurred while toilet training, then use some gradual techniques to make toileting a more positive experience.
relax your efforts while the child is constipated - first of all take the pressure off. Sometimes this involves a return to nappies so that there is a return to comfortable stool passage. Treat the constipation first.
Secondly when the constipation is treated encourage the child to tell you when he or she needs to go so you can calmly place a pull up on. When the child uses this reward on a chart.
Next is to get the child to fill the pull up or nappy in the toilet room. Each step is praised and rewarded
Finally the child will fill the nappy whilst sitting on the toilet. Then the nappy can be removed.
never punish a child for wetting accidents
If the child is fully toilet trained, then:
provide undisturbed relaxed times for use of the toilet
encourage a regular schedule for use of the toilet, usually 10-15 minutes after meals
assure the child can sit comfortably on the toilet with the feet flat on the floor
speak to the school-age child about bathroom facilities at school and their access to them when needed
