Constipation in children
Posted by Eamonn Brady on
Constipation in children
Constipation in infants and children and is rarely caused by an actual medical condition. In many children, constipation is triggered by experience of painful bowel movements or caused by factors such as toilet training, change in routine or diet, stressful events, illness like viruses or delaying defaecation (delaying going to the toilet).
Constipation can present at three common stages of childhood: in infancy at weaning; in toddlers learning toilet skills and at school age. Signs of straining in infants less than one year do not usually suggest constipation because children only develop muscles to assist bowel movements gradually. Provided that they pass soft stools and are otherwise healthy there should be no major problem.
What is constipation?
Constipation describes infrequent bowel movement, often with hard, dry stool that is difficult to pass. It may be associated with bloating, straining and pain. It is caused by inadequate muscle contraction or under absorption of water.
Diagnosing in children
The general diagnosis criteria for constipation in adults and children must include 2 or more of the following: 1. less than 3 bowel movements per week 2. History of painful or hard bowel movements 3. At least 1 episode of faecal incontinence (diarrhoea) per week 4. Presence of large faecal mass in rectum 5. History of stool so large that may obstruct the toilet
These symptoms must be present for 4 weeks in children under 4 years and for 8 weeks in children over 4 years in order to enable diagnosis
Risk factors for constipation in infants and children
*Many drugs - Antihistamines/anticonvulsants/iron supplements and many more *Intolerance to cow’s milk *Inadequate fluid intake *Poor diet including excess milk *Low fibre diet *Lack of exercise *Obesity
Treatment
Aim is restoration of bowel habit so stools are soft and passed without discomfort. Constipation may be Acute (short term) or Chronic (long term).
Treatment of acute constipation
Acute constipation refers to short term constipation that lasts only one to three weeks (generally brought on by short term illness eg. viral illness). In this case, ensure the child has adequate fluid intake and a good diet. If still no improvement, the GP is the next port of call. The GP may consider prescribing lactulose or Movicol® for a short period of one week. Movicol® is brand name for macrogol; the other brand is Molaxole® (for this article I will refer to as Movicol). Lactulose and Movicol are called osmotic laxatives, they work by drawing water into the stool and are considered to be the safest type of laxative as they do not stimulate the bowel muscle like laxatives such as senna. Laxatives if required are generally only required short term. If a child is prescribed laxatives, it is important a GP reviews progress regularly.
Treatment of chronic constipation
Chronic constipation refers to constipation that lasts longer term (eg) weeks or months. As constipation is long term, doctors may need to consider prescribing laxatives.
Age 1 to 6 months
If it is a problem from birth or meconium (sticky tar like faeces a baby passes for the first few days after birth) has not passed in first 24 hours then discuss with hospital staff as Hirschsprungs Disease or another complication is a possibility.
Other things to look at are type of milk (If formula fed) and ensure adequate fluid intake (150mls/kg). A dietician can advise.
Maintenance regime
If it is an ongoing problem, laxatives may need to be prescribed. Options are A. Macrogol (Movicol): ½ to 1 sachet daily or B. Lactulose: 2.5mls twice daily (adjust depending response) or C. Lactulose and Senna*: 2.5mls once daily.
Dis-impaction regime: if faecal impaction (ie. Blockage) has occurred
Movicol ½ - 1 sachet daily is a treatment option; if this is not tolerated then Lactulose and Senna are alternative options
Age 6 months to one year
*Ensure adequate fluid intake *Ensure overfeeding is not a problem and there is not excess milk *May benefit from dietician assessment if diet is thought to be poor *Abdominal pain, stomach bloating or vomiting occurs are worrying signs *An anal fissure (tear in anal skin that is painful when passing stools) is a possibility; easily rectified by medical intervention if it occurs
Maintenance regime and dis-impaction regime
Please note, the regime for this age is the same as the regime described above for one to six months (see above)
Children over 1 year
*Ensure adequate fluid intake *Adequate exercise? An active lifestyle can help bowel movement *Ensure regular toileting *Behaviour modification (eg) toilet training/rewarding/toilet diaries etc
Maintenance regime
Movicol dosage options are: 1-6 years: 1 sachet daily (adjust to response to max of 4 sachets/day); 6-12 years: 2 sachets daily (to a max of 4 sachets/day); Over 12 years: same as adult regime
Lactulose dosage options are: 1-5 years: 2.5 to 10mls twice daily (adjust to response); over 5 years: 5 to 20mls twice daily (adjust to response)
Senna* dosage options are: 1-4 years: 2.5 to 10mls once daily; over 4 years: 2.5 to 20mls once daily. Note: Senna should only be used if lactulose or movicol do not work
Dis-impaction regime: if faecal impaction (ie. Blockage) has occurred
Movicol dosage options are: *1-5 years: 2 sachets on day 1, then 4 sachets for 2 days, then 6 sachets for 2 days and 8 sachets daily thereafter *5-12 years: 4 sachets on day 1, then increase by 2 sachets daily until max of 12 sachets daily *Over 12 years: same as adult regime
If dis-impaction not achieved by 2 weeks, add a stimulant laxative like Senna.
Enemas can be considered in cases undergoing dis-impaction that do not have the required result from the medicine regime, if they are on maximum medication, and have been compliant with treatment. Enemas should only be used under specialist supervision
Disclaimer: please ensure you consult with your healthcare professional before making any changes recommended
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