Constipation in Children

Constipation is a common complaint in infants and children. There are many reasons but it 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

·         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. Constipation is thought to affect approximately 20 per cent of the population. It can be a symptom of a serious illness but this is rare. Once a serious illness is ruled out its management can involve dietary interventions and then only if this does not work, laxatives may be considered but only under medical supervision (ie) must be prescribed by a doctor

Diagnosing in children

The general diagnosis criteria for constipation in adults and children must include 2 or more of the following:

·         less than 3 bowel movements per week

·         a history of painful or hard bowel movements

·         at least 1 episode of faecal incontinence (diarrhoea) per week (this is due to an excess build-up of faeces which when suddenly released can cause diarrhoea

·         presence of large faecal mass in rectum

·         a history of stool so large that may obstruct the toilet

These symptoms must be present for 4 weeks in infants and children under 4 years and for 8 weeks in children over 4 years in order to enable diagnosis

What is ‘Normal’ bowel function in children?

The ‘normal’ frequency of bowel movements varies from child to child and varies widely

Examples of average bowel movements include:

Age	Average	Per Week
0-3 months	2.9/ day	5-40
3 years and over	1.0/day	3-14

 Bowel motions in breast fed babies can be very variable. It is not common, but some babies can have infrequent motions sometimes once in 7 or even 10 days

Risk factors for constipation in infants and children
 

·         Some 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

Constipation can be challenging to treat and often requires prolonged support, explanation, encouragement and medical treatment. Aim is restoration of bowel habit so stools are soft and passed without discomfort. Treatment starts with education of parents/carers and children (as appropriate for age).

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. You should see your GP if no improvement or it is causing distress to the child. If not improving, 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 the purpose of 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 even if it is only a short term use of laxatives.

Treatment of chronic constipation

Chronic constipation refers to constipation that lasts longer term, usually a period of weeks or months. In this section I discuss laxative use; however bear in mind laxatives are generally last resort and should be only used under medical supervision. However they are very beneficial if it is an ongoing problem

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, maintain on first formula for his/her particular age and do not    overfed)

·         Ensure adequate fluid intake (150mls/kg)

Maintenance regime

If it is an ongoing problems and diet, fluid intake etc have be assessed and are adequate, laxatives may need to be prescribed and these should only be maintained under regular medical supervision

Options include:

·         Macrogol (Movicol): ½ to 1 sachet daily

Or

·         Lactulose: 2.5mls twice daily (adjust depending response)

Or

·         Lactulose and Senna*: 2.5mls once daily  

Senna should be last resort as stimulant laxatives tend to case more side effects like lazy bowel than osmotic laxatives like lactulose and Movicol.

Dis-impaction regime: if faecal impaction (ie. Blockage) has occurred

Movicol ½ - 1 sachet daily; 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 (check with dietician)

·         May benefit from dietician assessment if diet is thought to be poor

·         Refer to specialist if abdominal pain, stomach bloating or vomiting occurs

·         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

·         May benefit from dietician assessment if diet is thought to be poor

·         Adequate exercise? Ensure an active lifestyle as this can help bowel movement

·         Ensure regular toileting

·         Behaviour modification :- toilet training/rewarding/toilet diaries etc (this can done by specialists

Maintenance regime

Movicol:

·         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:

·         1-5 years: 2.5 to 10mls twice daily (adjust to response)

·         >5 years: 5 to 20mls twice daily (adjust to response)

Senna*:

·         1-4 years: 2.5 to 10mls once daily

·         Over 4 years: 2.5 to 20mls once daily

*only if lactulose or movicol do not work

Dis-impaction regime: if faecal impaction (ie. Blockage) has occurred

Movicol:

·         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. If Movicol is not tolerated, use Lactulose and Senna for dis-impaction

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

References

References for this article are available on request. The article was written and researched by pharmacist Eamonn Brady and Eamonn will forward references upon request.

Disclaimer: Information given is general; please ensure you consult with your healthcare professional before making any changes recommended

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