What causes constipation?
The routine diet of children often contains food that increases the likelihood of developing constipation. These include cookies, fast foods, milk products and candy. Constipation also can occur when the child has had painful passage of stool and tries to withhold to avoid recurrence of the painful stooling. With time, if the stool is softened, the rectum gradually enlarges to hold more stool which then becomes harder to pass. This increases the discomfort, and the acute problem with hard stool becomes a chronic problem of constipation.
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What can be done to eliminate constipation?
The problems of constipation and encopresis can be overcome with time, effort and patience.
Structured toileting program
The most important thing to remember is that to improve bowel habits, you have to get your child to go to the bathroom. It doesn't matter if you adjust the diet or add stool softeners if your child won't go to the bathroom. The bowel contracts the most about 15 to 30 minutes after eating (gastrocolic reflex), so this is the best time to have your child try to have a bowel movement. Have him spend at least 10 to 15 minutes with each attempt. The child must try to relax in order to have a bowel movement; if he is straining, it is much harder to have success. Have him take a book or toy to pass the time in the bathroom, but be sure he is, in fact, trying to have a bowel movement and not just playing.
Rewards
Encouraging and rewarding children for good results is much more effective than arguing with them or punishing them for accidents.
Dietary changes
Various foods will help soften the stool naturally without medications. Unfortunately, most children are very stubborn about their diets and may not try certain food just because it is "good for them." Other children are picky eaters and getting them to eat ANYTHING is difficult enough, let alone putting them on a special diet. This information is here for you to try with your child, if you can.
Increased fluid intake
Increasing fluid intake will help with softening the stool and keep the urine dilute as well. This has the additional advantage of potentially improving voiding discomfort and cutting down on UTIs. Certain fluids (clear juices -- apple, white grape juice, prune juice) are better than others. Milk and milk products (cheese, ice cream) can cause constipation. If your child is very constipated, it is better to somewhat restrict intake of milk products. You don't need to eliminate them from the diet entirely. Moderation is the best treatment in this instance.
Increased fiber from food
Increasing fiber gained from foods will also soften the stool and make it easier to evacuate. High fiber foods include whole grain breads, bran or barley cereals, added bran in prepared foods (such as hamburger, spaghetti sauce, on top of other cereal), and fruits and raw vegetables (celery, lettuce, pear, apples, plums, peaches, grapes). A bowl of cereal containing bran, for breakfast or as a snack, is a good source of added dietary fiber. Keep to a minimum those foods that cause constipation, such as bananas, rice, rice cereal, applesauce, white bread, carrots, pasta, cheese or desserts with refined flour or sugar. Learn which other foods may constipate your child and try to avoid them as much as possible.
Medications/fiber supplements
Occasionally, even with attempts to change the diet, medications or fiber supplements may need to be used. Some children are so impacted with hard stool that they need disimpaction before they can be placed on a good bowel regimen. (They won't go if it hurts too much.) Baby Fleets enemas or 1/2 of an adult Fleets enema can be used to empty out hard impacted stool. Usually, one enema (preferably two enemas) will give a good cleansing so that set bathroom times and dietary measures can be started with better effectiveness.
Laxatives
Although not recommended for long-term use, laxatives are often needed to get the child to have more frequent, softer stools so that regular bowel habits can be reestablished. Some laxatives that may be used are: listed below.
- Milk of Magnesia (MOM), given twice a day
- Mineral oil, given once or twice a day
- Lactulose (10gm/15 cc), given once or twice a day
- Senna (Senokot), one to two tsp. once a day (usually at bedtime). Amount depends on age and weight
Laxatives are generally given daily, or dose-adjusted to get one or two bowel movements a day or loose but not liquid movements, which allows complete daily emptying of the bowel and prevents soilage and abdominal pain. Laxative use should be routine for at least three months; then tapered off over several months. Occasionally, laxatives are needed for longer time periods but are not recommended for long-term continuous use unless there is a neurologic or anatomic reason for continuing full time (e.g., spina bifida or spinal cord injury patients).
Fiber additives
Fiber products have improved over the past years to become more palatable for even the toughest taste buds. Some of these are in the shape of fiber bars with variable amounts of sugar (e.g., Metamucil fiber bars). The ultra-fine powders are tolerated if given in cold water or juice, particularly at mealtime (so it is less like a medicine). These include Metamucil Smooth Fiber or Citrucel. (Both come in orange flavor and are sugar-free). These may be easier to get the children to drink than prune juice. Some fiber products can be sprinkled on food and not give any bad taste. Ask the pharmacist about these fiber additives. You may need to try one or both of the fiber products, as some children may have increased gas with certain products. Most tolerate them without any problem and may have less painful, more regular stools because of the fiber.
Refractory constipation/encopresis
If there is no improvement in bowel habits (still hard or large movements, continued or abdominal pain), your child would then benefit from a more complete evaluation and closer management by a gastroenterologist (bowel specialist). This specialist can evaluate your child with various X-rays or direct visualization (endoscopy) of the bowel and suggest different or more intensive therapy.
By improving your child's bowel habits, his bladder infections or wetting should also improve. It takes time and patience but the results will be worth it.
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