What is Constipation?
Constipation is a common cause of abdominal pain and loss of appetite in children. When we start eating, there is a reflex called "Gastro – colic reflex" that causes the Colon (Large intestines) to constrict and gives an urge to defecate.
If the colon is filled with hard stools this reflex will cause pain and the child will stop eating. Eventually, the child will refuse eating all together to avoid this painful sensation.
Constipation has significant impact on a child, both physical and psychological/ behavioral. A child that has passed painful stools will try to avoid going to the toilet again to prevent pain. That creates a "vicious cycle", it will cause retention of more stool in the colon, stretching of the colon to a point in which the colon doesn't function properly and worsening of the constipation. A child that suffers from longstanding constipation may lose the ability to control his anal sphincter and may suffer from "leakage" of small amounts of loose stools and staining of his underpants.
This problem has a great emotional impact on a child. It causes the child to be afraid of the toilet. It will cause a child to feel embarrassed, try to avoid certain social situations (avoiding public toilets at school, avoiding visiting friends) and suffer from low self esteem.
Constipation is a common condition in toddlers and children but it is uncommon in little babies. Sometimes, normal phenomena might be mistaken as constipation.
‒ Babies who are exclusively breastfeeding or formula feeding can pass stools anywhere from 6 times a day to even once a week. Usually, when they do pass stool, it is soft and not painful.
‒ Straining: This is a situation where the baby seems to be struggling to pass stools. He grunts and strains and even turns red and eventually he passes stools which are soft. This is a result of incoordination between using abdominal muscles to push the stool out and squeezing the anal sphincter which makes it difficult to defecate. Eventually, the baby learns to relax his sphincter and the straining situation is resolved.
If a baby does suffer from true constipation - we need to search for a cause:
‒ Milk allergy: Constipation may be the only sign of Milk allergy in little babies. Sometimes there can be blood in the stool.
‒ Anatomic conditions (Bowel obstruction, Hirschsprung disease, Hernia)
‒ Hypothyroidism (Low thyroid hormone)
‒ Dehydration, Malnutrition
‒ Botulism (From exposure to honey)
‒ Rare metabolic disorders.
The treatment of constipation involves 3 aspects:
‒ Avoid Sugary sweet foods and drinks (including fruit juices), fatty foods, large amounts of white rice and bananas. They may worsen constipation.
‒ It's better to blend the whole fruit than to give only the juice, your child will get more vitamins, minerals and fiber this way.
‒ Give your child foods rich in fibers (whole rice, cereals such as Oat, whole fruits and vegetables, whole grain bread).
‒ Blended prunes (especially dried prunes) can sometimes help with constipation.
‒ Adding 1-2 spoons of olive oil to your child food may help.
‒ Make sure your child drinks plenty of water (Not juice!)
2. Stool softeners:
If nutritional changes don't help, the next step is to use stool softeners. There are different types in the market. I usually prefer to use "Duphalac" or Lactulose. It is a special type of sugar that is not absorbed, it retains water inside the gut and loosens the stool. I prefer not using suppositories (such as microlet or glycerine) as they are less effective, and sometimes may even be traumatic for the child.
The goal is to get stools as soft as toothpaste. Not firm and not too loose. Start with a low dose (1/2 – 1 sachet) and gradually increase every 2-3 days until you reach the desired goal. Continue this dose daily for at least 3 – 4 months.
The treatment usually lasts for several months for a couple of reasons:
‒ It takes time for the dilated rectum to get back to its normal size and function.
‒ It takes even longer time for the child to forget the pain of passing hard stools. There is no risk of "Addiction" or "getting used" to this treatment.
3. Behavioral plan:
‒ Encourage your child to sit on the toilet twice a day, after breakfast and after dinner. This way you can use the "Gastro colic reflex" that happens after eating. Let the child sit there for a few moments even if nothing happens just to get him familiar with the situation.
‒ Remember, when your child is on the potty or the toilet seat – make sure his knees are higher than his hips. Squatting is even better. It makes it easier to pass stools in this position.
‒ Make it fun: This is for toddlers and preschool children: Prepare a "Calendar" and every time your child successfully passes stools, put a little sticker there. Every 7 stickers go together and let him choose a little gift to get as a reward. This will motivate the child to "make an effort".