I get asked multiple times what's the best management for their child’s constipation which is not surprising as constipation affects around 30% of children and most commonly arises around the time of the introduction of solids, at the onset of toilet training or at times of stress or change in the child’s life, such as starting school. Normal bowel movements for children are highly variable depending on several factors but commonly, children over 6 months of age will open their bowels 1-2 times per day.
Around 95% of cases of constipation in children arise from a functional issue meaning there is no underlying medical condition. However, constipation in babies before the transition to solids or under 3 months of age have a higher likelihood of having a medical cause and advice should be sought from a medical professional.
In most cases, the cause of functional constipation is behavioural withholding where a child resists the urge to go and therefore stool builds up in the colon and rectum leading to fluid being reabsorbed into the large bowel. This results in a harder and larger stool to pass which makes defecation painful and therefore often more withholding. Over time the colon can become stretched which leads to uncontrolled soiling which is often mistaken by parents as having loose bowels or diarrheoa instead of being a sign of overflow from impaction.
How is constipation diagnosed?
Constipation is more complex than just not having a bowel motion. The definition of constipation is having 2 or more of the following symptoms for more than 1 month:
· 2 stools or fewer per week
· Excessive stool retention
· Painful or hard bowel motions
· The presence of a large stool in the rectum
· A history of a large diameter stool
· More than 1 occasion per week of faecal incontinence after the child is toilet trained.
How is constipation treated?
Firstly, after consultation with your child’s GP or Paediatrician, disimpaction of the child’s bowel will need to happen. This means the build-up of stool is removed. This is usually done through an oral laxative. Once there has been at least 1 week of watery soft stools, treatment progresses to maintenance therapy.
Maintenance therapy involves a combination of dietary therapy and behaviour modifications. The diet should include adequate fluid intake to ensure stools are soft and easier to pass. Most younger children need around 1.0-1.2L of fluid per day and older children (>8yrs) will need 1.4-1.9L/d.
Dietary fibre also needs to be increased. It is important to note that increasing dietary fibre without increasing fluid may make the constipation worse and that’s why I always recommend fluid intake is increased first. It is recommended that dietary fibre comes from a well-balanced diet which includes whole grains, fruits and vegetables. Fruits such as stone fruits, pears, apples, prunes and avocados as well as watered down prune, pear and apple juice are strongly recommended as these fruits and juices are high in non-absorbable carbohydrates known as sorbitol and polyols and help to draw water into the bowel creating a softer stool. However, it is recommended that juice alone is not the only source offered as the process of chewing helps to stimulate the gut and the need to pass stools, and therefore a combined intake of the physical fruit and the juice is beneficial.
Cow’s milk protein (CMP) allergy or intolerance can also cause chronic constipation and therefore if the above treatments strategies have not worked, trialling a removal of CMP for 4 weeks under medical supervision may be of benefit to rule out a possible allergy or intolerance. Your child’s diet will need to include alternative dietary sources of protein and calcium to ensure dietary needs are met.
Positive toileting behaviours are also highly effective and part of the maintenance therapy. Children should be encouraged to sit on the toilet after meals, for instance 3 times a day for no longer than 10mins each time. This process should be unhurried and positive. The use of books or toys can be offered as a distraction to reduce stress and anxiety. The child’s seating position is also important. The child’s feet should touch the floor or a foot stool, and seated in an upright non-slouched position.
When constipation is not from a functional cause.
Only 5% of cases of constipation arise from an organic cause or result from an underlying medical condition. Most of these cases present in early infancy, however other red flags include the following, and advice from a Paediatrician is necessary.
· Onset before 1 month of age
· Delayed passing of meconium
· Rash, red sore eyes or mouth ulcers
· Intermittent and explosive diarrhoea
· Weight loss/poor growth or persistent vomiting
· Brown or dark coloured blood in the stool
· Developmental delay
· No history of withholding or incontinence
If you would like more help managing your child’s constipation, please call us on 0418 962 149 to book a consultation.
Nurko, S & Zimmerman LA. Evaluation & Treatment of constipation in children and adolescents: American Academy of Family Physicians 2014: 90 (2) 82-90
National Health & Medical Research Council. (2014) Nutrient Reference Values - water. Retrieved 17th December 2019 from https://www.nrv.gov.au/nutrients/water
The Royal Children’s Hospital (2017) Melbourne RCH. Constipation. Retrieved 17thDecember 2019 from https://www.rch.org.au/clinicalguide/guideline_index/Constipation/
Tabbers, M.M. et al. Evaluation and treatment of functional constipation in infants and children: Evidence-based recommendations from ESPGHAN and NASPGHAN. J of Pediat Gastro and Nutr, 2014:58(2), 265-281.
Singh H & Conner F. Paediatric constipation: An approach and evidence-based treatment regimen. Australian Journal of General Practice. 2018: 47:5, 1-10.