Constipation - Child

Definition
There is no agreed definition of constipation as everybody has a different bowel habit, some children open their bowels once or twice a day, others only every two or three days. Most people expect the suggestion of constipation to include infrequent bowel actions and hard stools, but it is not always so.

The symptoms of constipation can differ with age. Artificial or bottle milk can cause constipation in babies, especially before solids are introduced. A baby's bowel works automatically so when he feels the urge to open his bowels, he will try to do so immediately. Constipation can lead to colic causing the baby to lift up his legs and cry, he may go red in the face trying with no result or the stool may be partially evacuated and then retract. Eventually after much effort a hard stool is passed, possibly tearing the anus so a small amount of bright red blood is seen on the surface of the stool. Offering baby fruit juices may be enough to soften the stool. Once the baby is weaned the constipation usually resolves.

Toddlers
A common complaint in toddlers is that they are straining to pass stool sometimes for several hours or a day or so before success. On careful questioning though, the toddler is standing up, often rigid with his legs tight together. What is really happening is that he is stool-withholding. Far from trying to pass a stool, he is desperately trying not to pass a stool often because he has learnt that it will be painful. Eventually he becomes constipated attempting to avoid pain. Normally the original cause of this behaviour remains a mystery, although it may have started when a hard painful stool was passed sometime previously.

Treatment
Treatment consists of softening the stool with a laxative to stop the pain when passing a stool and increasing stool frequency, ideally to daily using a stimulatory laxative. As the bowel has been stretched by constipation, several months of laxative treatment may be necessary for the bowel to return to normal which it eventually will do.

Older Children
In older children constipation may be obvious because of infrequent stools, sometimes only once every two to three weeks, frequently with soiling of the underwear, sometimes with solid matter sometimes just “skid marks”. Other children may apparently be opening their bowels regularly, but complain of stomach ache (abdominal pain) just after meals or just before a stool is passed. Examination of the stomach may reveal excess stool, but x-ray often shows a very constipated large bowel. Again the cause usually remains a mystery although many children dislike opening their bowels in the school toilets, so suppress the urge. If this is repeated regularly, constipation occurs.

Treatment
Treatment here consists of a “spring clean” when the large bowel is completely emptied of stool. Then a softening laxative and stimulatory laxative are used to ensure regular passage of soft stool and that the bowel is properly emptied each time.  This laxative treatment may need to continue for many months, possibly 9 to 18 months and sometimes longer to allow the stretched bowel to return to normal.

Diet can be helpful, but managing to persuade a stroppy toddler or teenager to eat large amounts of fruit and vegetables can be difficult. Any increase in fibre is worthwhile, but it is a balance between encouraging increased fibre in the diet and turning meal times into a battlefield.