Constipation in children: solution guide to parents

Constipation is very common and also mismanaged problem of children.  A detailed knowledge of the problem and how to tackle is needed to overcome it. Parents often practice various unsuccessful modes of treatment but for a short period of time.

How constipation becomes a disease

All start with a single event of painful stool passage following stool withholding (that can be due to change in place, eating habits, illness, drugs etc.). This withholding makes the stool stay in the rectum for prolonged period.  It leads to harder and wider stool. This wider diameter and harder stool is more painful to pass, so the child again try to withhold it and thus the vicious cycle continues.  When a short course laxative is given or a suppository is applied only a small amount of stool is passed without clearing the entire rectum. This leads to a chronic problem.

Why we need to know about constipation

1)      Almost 30 % of paediatric patients suffer from constipation.  That means 1 in every 3rd child has this problem
2)      If not detected and treated early it becomes chronic and long-term problem
3)      Off and on treatment don’t cure the issue

What is constipation

Difficulty or delay in passage of stool sufficient enough to cause distress to the patient is called constipation. 

This is more of subjective definition.  To overcome it, now we have ROME IV diagnosis for constipation: presence of 2 or more of the following criteria for more that 4 weeks

i)        2 or less stool per week
ii)       1 or more fecal soiling per week after acquired toilet training
iii)      History of excessive stool retention
iv)       Painful stool passage
v)        Presence of hard mass on abdomen
vi)     Passage of large diameter stool that can obstruct toilet

What are the symptoms of constipation?

Common symptoms of constipation are
1)      Child is not passing stool daily: stool frequency varies from age to age. But in general, every child should pass soft stool daily. A constipated child pass less than 2 stool per week.
2)      Fecal incontinence: that is passage of stool in the undergarments.
3)      Stool retentive posture: child is attaining bizarre posture, hiding in the back, legs often crossed trying hard to retain or withhold stool (parents often think their child is trying hard to pass the stool but it is the opposite)
4)      Painful and hard passage of stool, sometimes bleeding after stool
5)      Presence a small skin tag near anal opening, known as sentinel pile
6)      Presence of hard or soft indentable masses in the abdomen
7)      Passing of large diameter stool

Types of constipation
 
A)      Functional: common, almost 90 % of cases are due to it
B)      Organic: due to diseases like Hirschprung, Hypothyroid, cystic fibrosis, coeliac disease etc..

Do we always need any investigation to diagnose constipation?

No, as most cases are due to functional constipation.

What are the red flag signs of constipation?

Delayed passage of first stool/meconium, onset in early infancy, failure to thrive, abnormal neurological examination, developmental delay, ribbon or pellet stools, bilious vomiting, uniform abdominal distention.

How to treat constipation in children:
4-pronged treatment is needed.

1)Counselling: parents must know the cause of it, course of the problem, how to treat, duration of treatment and need for regular follow up.  Until parents and caregivers are well versed with all the aspects of it, treatment is likely to fail.

2)Toilet training:
Age when toilet training should start: 2 yrs of age
How: Rule of1 to be followed
by 1 person (only one caregiver should be responsible for training)
1 routine: 5 to 10 minutes after meals
1 place: a fixed toilet, preferably Indian style sitting is better
1 word like pooh, potty etc
 
Only one caregiver should make the child sit in a fixed toilet for 5 to 10 minutes after a meal and say a fixed word like potty
Treatment of anal fissures is must to make the defecation painless

3)Diet, Fibre and water intake
Dietary modifications and adequate water intake are needed to have a successful treatment.
However, parents should know that only dietary modifications are not sufficient enough to treat childhood constipation. 
Diet: Diet rich in fibre like whole cereals, pulses, vegetables and fruits to encourage. Restrictions on milk, fruit juice, junk and ready to eat food has to be taught.

4)Drugs: Medicines are needed to treat constipation.  As mentioned earlier, dietary modifications and toilet training are not sufficient to overcome this issue.

Which drug: Either polyethylene glycol preparation (powder or syrup) or Lactulose. Both are equally effective in treatment of constipation. Parents should know 3 things before starting drug therapy

1)      Disimpaction of stool is must before starting maintenance therapy: a paediatrician or gastroenterologist will know after examination who will need disimpaction treatment
2)      Long term therapy is needed: most cases of paediatric constipation needed 15 to 18 months of treatment before drug can be stopped
3)      Regular follow up with a paediatrician or gastroenterologist is must: to monitor progress, dose of drug and when to stop.  Medicines are stopped gradually over 3 to 6 months period.

Common causes of treatment failure:

1)      Starting maintenance dose of medicines before disimpaction
2)      Premature stoppage of medicines
3)      Not doing regular follow up
4)      Not treating associated disease like anal fissure
5)      Organic cause of constipation

 
 
TAKE HOME MESSAGE

1) Constipation is very common in children
2) Most cases are due to functional constipation
3) Parents should know proper age and methods for toilet training to prevent constipation
4) Dietary modifications and toilet training are not sufficient enough for its treatment
5) Very safe and effective drugs are available for its treatment
6)  Long term treatment is must, often 15 to 18 months
7) A regular follow up is needed to cure this problem