Children and Constipation Normal bowel habits are a sign of health in children. Parents pay close attention to how often their children have a bowel movement (BM) and what it looks like. Anything out of the ordinary may be cause for a trip to the doctor. But how do you know when and when not to worry? This pamphlet will help you understand what is constipation and possible treatment options. What is constipation? • as stools stay in the colon they become bigger and harder, Constipation is very common in children. It is not a disease and it can be resolved. Constipation often becomes a family problem because when a child is constipated the entire family may find the situation stressful. Constipation can be defined as: • a decrease in frequency of bowel movements, 2 or less times/week. • stools that are hard, dry and shaped like balls, pebble-like stools. Even if this occurs daily. • stools that are painful and • • difficult to pass. very large stools that can block the toilet. with or without soiling underwear. • stretching the colon. The stools then are more difficult and painful to pass. This creates a cycle of: bowel movement = pain. child continues to hold in his/her stool. What are the symptoms of constipation? • • • • • • painful bowel movements stomach pain/abdominal bloating rectal bleeding from tears (fissures) poor appetite irritability/crankiness urine problems (recurrent infections,bedwetting, retention). AVERAGE FREQUENCY OF NORMAL BOWEL MOVEMENTS Age # of times/day 0-3 months 6-12 months 1-3 years 4y & older 2-3 2 1.5 1 The most common cause of constipation is functional and not due to an underlying disease. Functional constipation begins when a child has a painful bowel movement . The child then holds in the next bowel movement because of the pain he/she previously experienced. THE FUNCTIONAL CONSTIPATION CIRCLE Holding/retention After a child passes a stool that causes pain he/she will not want to have another bowel movement. So the child will start holding. This holding/ retention often becomes an unconscious and regular habit. What are the signs that your child may be holding a bowel movement? • it may look like your child is trying to push, however he/she is • • • • • • • • probably trying to hold the stool in. hiding in a corner/holding on to furniture. wriggling on the floor/unusual positions. crossing their legs. their body is stretched and clenched/up on their toes. dancing back and forth from one leg to another. they may clench their buttocks. refusal to have a bowel movement. fear of the toilet. Possible causes of holding/retention • child feels the need to have a bowel movement (BM). • child holds in his/her stool for fear of pain. • urge to go passes. 2 • • • • • • • • • • • • • previous painful anal experience toilet training stressful event changes in the diet/routine travel viral illness/gasto-enteritis bad diaper rash starting school / summer camp hard stools, suppositories, enemas, dilatations ignoring the urge to go for a bowel movement/too busy toilet not available use of certain medications sexual abuse 3 Complications of constipation Encopresis Fecal impaction: • uncontrolled release of stool in underwear. • • • • • This is not a defiant behaviour. Your child cannot feel what is happening. Cause: when a stool is so big it stretches the rectum, the sensation to have a bowel movement decreases. When this happens, liquid or soft stools seep around the large stool mass. This leaks out without the child feeling it. This is a common complication of severe constipation and may be confused with diarrhea. • accumulation of a large, firm stool mass called a fecaloma found during a physical exam and/or abdominal x-ray the stool is difficult or impossible to pass Symptoms: > abdominal pain/bloating > sensation of rectal fullness > nausea and vomiting > encopresis if left untreated it can become big enough to provoke intestinal blockage and urinary problems. Fissures: Rectal prolapse: • a superficial cut in the lining of the anal canal caused by excessive • rectal lining that bulges through the anus. This is caused by • stretching during the passage of a large, hard stool. Symptoms: > severe pain or burning sensation > pain during and after a bowel movement > anal itching > bright red blood on stool or toilet paper • Hemorrhoids: • hemorrhoids are veins that are a normal part of the human body but they become dilated and visible when increased straining • hemorrhoids can be internal and/or external • External hemorrhoids are the most common in children . There are no symptoms. • Symptoms of internal hemorrhoids: > are more obvious in older individuals > are revealed as a bulge outside the anus and by bleeding and itchiness around the anus. increased abdominal pressure when straining. It may also be a result of weakness or stretching of the muscles that support the rectum. Symptoms: > a mass bulging from the rectum when the child is having a bowel movement. It looks like a donut with wrinkles. > mucus discharge > rectal bleeding > fecal incontinence > most frequently due to constipation and repeated straining, but could be due to diarrhea, parasites and various diseases Failure to thrive: Constipation can cause fullness. This may decrease your child’s appetite, which could affect his/her weight gain. If there is a severe decrease in growth, other causes of the constipation need to be looked at. Psychological complications: • • • • 4 decreased quality of life decreased self esteem social withdrawal denial is often a coping style 5 Other conditions Treatment Infant Dyschezia 1- Education / demystification 2- Disimpaction (not always necessary) 3- Maintenance • at least 10 minutes of straining and crying before successful • • passage of a soft stool. This occurs in an otherwise healthy infant less than 6 months old. it is the result of incoordination between increased abdominal pressure and pelvic floor. it resolves spontaneously with time. a. Behavioural Modification b. Diet c. Exercise d. Medication 4- Wean/Observe Hirschsprung Disease: Normally, muscles in the intestine push stool to the anus. Special nerve cells in the intestine, called ganglion cells, make the muscles push. A person with Hirschsprung Disease (HD) does not have these nerve cells in the last part of the large intestine. In a person with HD, the healthy muscles of the intestine push the stool until it reaches the part without the nerve cells. At this point, the stool stops moving. New stool then begins to stack up behind it. Hirschsprung is typically diagnosed soon after birth however it may go undiagnosed until childhood. It may be associated with bloating and possible growth retardation and may present as a constipation which is very hard to treat. Compared to functional constipation there is also the absence of significant encopresis. Rarely are the stools large, they are more “ribbon-like”. It is also rare to have holding/retention behaviour. Treatment requires surgery to remove the affected area. 1- Education / demystification Treatment of constipation requires patience and time. Retraining is needed to make the body/brain forget the pain when having a bowel movement. This is a long process with gradual improvement and relapses. Any painful bowel movement can result in a relapse. Our healthcare team is here to coach and support your child and yourself. This includes follow-up visits and phone calls. We encourage parents to maintain a consistent, positive and supportive attitude in all aspects of the treatment. 2- Disimpaction • may be necessary before maintenance therapy. • accomplished with either oral or rectal preparations . The oral • approach is favoured because it is not painful and it gives the sense of power to the child. discussion with you and your child will help in choosing the best option. The longer constipation goes unrecognized, the more difficult it is to treat. 6 7 3- Maintenance 3a. Behaviour modification • Start regular toilet sessions 2-3 times/day • Encourage unhurried time after meals for bowel movements • Encourage child to go to the toilet when the urge is felt (avoid holding/retention) • Keep a diary of stool frequency –this can be used as positive reinforcement by parents and doctor • Use a reward system – stickers on a calendar chosen by your child CLASSIFICATION LUBRICANTS: Mineral oil Lansoyl ACTION • softens and covers the stool making it difficult to hold and easier to push out. • it is not absorbed by the body. • it is NOT recommended for children under 1 year old. • special precautions must be taken if your child is refluxing or is handicapped. • the dose may be divided and taken anytime during the day but AVOID giving it before bed. • it can be mixed with any type of food. • theoretical interference with the absorption of minerals and vitamins. • leaking of oil in the underwear may be an inconvenience of this medication. • lactulose is a sugar that is not absorbed. • lactulose provokes the colon to secrete water which stimulates contractions of the colon. • also acts as a stool softener. • side effects: flatulence and cramping if dose increased too fast. • MOM: infants susceptible to magnesium poisoning, use caution in renal impairment. • sorbitol is also found in some juices-apple, prune, pear. • mimicks a diet rich in fibre. • acts like a sponge when in contact with water. This increases the size of the fecal mass. • the larger mass stimulates contractions of the colon. • the child must be well hydrated and active for best results. • must be taken with plenty of liquid to avoid increased constipation or intestinal blockage. • absolutely do not use in patients with intestinal obstruction or narrowing. 3b. Diet We favour a balanced diet but we do not recommend forcing the diet. • You can enrich the diet with fibres as recommended by the Canadian Food Guide. Simply follow this formula: AGE + 5 = total amount of grams of fibre/day • Drink plenty of liquids during the day 3c. Increase exercise 3d. Medication It is beneficial to add oral medication to behaviour modification. This will achieve positive results sooner. Finding the right medication and dosage may be difficult and long. But once the right “formula” is found your child will stay on this for about 4-6 months or longer. When your child has been having regular bowel movements, without difficulty, the medication can be slowly decreased and then stopped. Your doctor will decide when your child should be weaned from the medication. This will also be a slow process so a relapse will not occur. OSMOTICS: Lactulose Milk of magnesia (MOM) Sorbitol Citro-Mag The most common medications we use to start a treatment are: mineral oil, lansoyl, lactulose and PEG 3350. They are safe and effective. We do not recommend suppositories or enemas as this is a painful experience, which favours the circle of “pain and holding” described earlier. Use these only when recommended by your doctor. MUCILAGES: Fibre substitute Metamucil Prodiem Benefibre COMMENTS ...continued on page 10 8 9 CLASSIFICATION EMOLLIENTS: Colace ACTION • softens stools. • easier to push out the stool. COMMENTS • DO NOT use in combination with mineral oil to avoid absorption of the mineral oil. Tricks to remember • Treatment takes time. Don’t get discouraged, it is a gradual process and relapses may occur. • The secret to the success of treatment is to take the treatment properly and DO NOT STOP it too fast. STIMULANTS: Dulcolax Senekot Ex-Lax RECTAL PREPARATIONS: Suppositories • Glycerine • Dulcolax Enemas • can provoke cramps and diarrhea. • use intermittently and for short periods of time only under the recommendation of your physician. • if used often these medications can cause a “lazy bowel“ which is difficult to reverse. • A normal stool has the consistency of toothpaste or peanut butter. • Try to have daily bowel movements to prevent build up. This allows • stimulate and lubricate. • main action is to increase the size of the rectum and provoke the sensation of the need to go. • to be used occasionally for constipation. • risk of mechanical trauma to rectal wall. • when this medication is needed your physician will recommend which one to use. • perpetuates “viscious circle of pain and then holding”. • DO NOT use soap suds, tap water or Mg enemas. • • provoque diarrhea (osmotic agent) • may be difficult to take due to bad taste and amount or quantity required. • may cause nausea, cramps, vomiting. • stimulates intestinal nerves therefore provokes contractions of the colon. • produces drastic effects in emptying the intestines quickly. the rectum to return to normal size. • Stop holding/retention behaviours. • Adopt the habit of checking food labels for fibre content. • You can refer to our fibre sheet . This gives quantities and grams of fibre for many different foods. • Increase fibre intake gradually. At the same time increase fluid • • intake, to prevent your child from becoming more constipated. Parents need to maintain a consistent, positive, supportive attitude in all aspects of treatment. Promote responsibility and independence for going to the bathroom. Our team is there for YOUR CHILD AND YOU. LAVAGE: Polyethylene glycol (electrolyte solution) • Peglyte • Golytely • Colyte Polyethylene glycol powder (PEG 3350) (without electrolytes) • LAX-A-Day • Miralax (US) • Forlax (FRANCE) • Movicol (ENGLAND) 10 • osmotic agent. • cause water to be retained in stools. • make stool soft. • increase frequency of stool. • easy to take. • safe. Bibliography Baker S. S and al. A medical position statement by NASPGHAN. Constipation in infants and children: Evaluation and Tx JPGN 29:612-626 Hyman P. and al. Childhood Functional Gastrointestinal Disorders: Neonate/Toddler. Gastroenterology 2006; 130: 1519-1526. Rasquin A. and al. Childhood Functional Gastrointestinal Disorders: Child/Adolescent. Gastroenterology 2006; 130: 1527-1537. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease 7th Edition. Wyllie/Hams Pediatric Gastrointestinal Disease Second Edition. 11 This booklet was prepared by Dr. Dominique Levesque, M.D., pediatric gastroenterologist and Director of The Montreal Children’s Hospital Motility Lab and by Sandra Kambites, RN, BScN Motility Lab Nurse. It was reviewed in collaboration with the Gastroenterology Service and the Department of Surgery. Special thanks to Dr. Jean-Martin Laberge. Funding for this booklet was made possible thanks to the Auxiliary of the Montreal Children’s Hospital of the MUHC. 2300 Tupper Street Montreal, Quebec H3H 1P3 514.412.4400 www.thechildren.com April 2009 IMPORTANT : S.V.P. LIRE L’information fournie dans cette brochure sert à des fins éducatives. Celle-ci ne doit aucunement remplacer les conseils ou directives d’un médecin / professionnel de la santé, ou servir de substitut à des soins médicaux. Veuillez communiquer avec un médecin / professionnel de la santé si vous avez des questions concernant votre état de santé.