How to manage child constipation

Is your child struggling with constipation? If yes, it often can be very distressing for both your c

Is your child struggling with constipation? If yes, it often can be very distressing for both your child and yourself. However what we do know is that constipation is very common affecting up to 30% of children and often arising around the time of transitioning to solids, toilet training and school entry (1,2).

In children it is estimated that 95% of cases of constipation are functional, that is there is no medical cause for the constipation (3). However it should be noted that constipation presenting before 6 months of age, and particularly before 3 months of age does have a higher chance of being related to an underlying medical cause.

The main contributing factor for children developing functional constipation is behavioural withholding after a painful or unpleasant stool event. This unfortunately causes the stool to build up within the colon and rectum leading to fluid reabsorption and harder, larger and more painful stools to pass. Overtime the colon and rectum stretch which leads to a reduced sensation of ‘needing to go’ and involuntary soiling.

How is constipation diagnosed?

Whilst we often think as constipation as not opening bowels, the actually diagnosis is more complex. Based on the Rome IV criteria functional constipation is diagnosed by the presence of two or more of the following features at least once per week for minimum one month:

• Two or fewer stools per week
• Excessive stool retention
• History of painful or hard bowel movements
• Presence of large faecal mass in rectum
• History of large diameter bulky stools that may obstruct the toilet
• At least 1 episode of faecal incontinence per week after toilet training completed (4)

What medical treatment is required for constipation?

If your child has not seen their paediatrician or GP I would highly recommended booking an appointment, especially if they have been suffering with constipation for over a month and are meeting the above criteria. Often the first step in treatment for children with chronic constipation will be disimpaction, which is the removal of the build-up of stool in the colon. This is most commonly completed with the use of oral laxatives.

What dietary and lifestyle factors can assist in the management of constipation?

Encourage positive toileting behaviours

Improving your child’s toilet routine is essential for successful long-term management. Encourage your child to sit on the toilet for 5-10 minutes after meals, up to three times per day. It is also important to ensure this is a positive experience for the child and they are not rushed. For some children a reward system to chart progress may work well however it is important to note that toilet sitting should also be praised, even if no stool is passed. Correct seating on the toilet will also help to ensure more easy bowel movements. Feet should be supported and knees just above their hips. To help support feet a small stool or otherwise books could be used.

Appropriate fluid intake

Ensuring a good fluid intake will help to ensure stools remain soft and easier to pass. As a general guide children under 8 need around 1-1.2L/day, whilst older children 1.4-1.9L/day. To help meet these requirements offer water with meals and snacks and invest in a cute/fun drink bottle they can take to day-care, preschool or school.

Adequate fibre intake

Whilst fibre alone will not resolve the constipation, adequate intake can help to improve stool consistency. Low intake has also been shown to be a risk factor for child constipation. Currently the recommendation is for a balanced diet that includes whole grains, fruits, and vegetables (5). Due to lack of evidence regarding efficacy of fibre supplements they are not recommended in the treatment of child constipation (6).

Increase non-absorbable carbohydrates

Non-absorbable carbohydrates such as sorbitol (e.g. prune, apple, pear juice) has been found to help increase water absorption in the bowels leading to softer stools, particularly in infants (6). The recommended dose in infants is 60mL juice/day diluted in 60mL water daily (2). For older children diluted fruit juice could also be trialled. It can also be beneficial to include high sorbitol containing fruits such as stone fruits, apples, pears and prunes.

Consider potential food allergy or intolerance

Cow’s milk protein allergy or intolerance has also been implicated in chronic constipation (6,7). If your child does not improve with the standard treatment it may be worth discussing with your healthcare professional whether there could be an underlying cow’s milk allergy or intolerance. If suspected a cow’s milk exclusion diet may be trialled for 2-4 weeks under medical supervision (6,7). In this time alternative calcium sources will be required to ensure adequate calcium intake.

If you feel you need more guidance managing your child’s constipation please call the clinic on 9570 1277 to book an appointment.

References:

• Waterham, M, Kaufman, J & Gibb, S. Childhood constipation. Australian Journal of General Practitioners 2017; 46 (12): 908-912.
• Nurko, S & Zimmermann, L. Evaluation and treatment of constipation in children and adolescents. American Family Physician 2014; 90 (2): 82-90.
• Levy, E, Lemmens, R, Vandenplas, Y & Devrekeret. Functional constipation in children: challenges and solutions. Paediatric Health, Medicine and Therapeutics 2017; 8: 19-27.
• Hymas, J, Lorenzo, C, Saps, M, Shulman, R, Staiano, A & Tilburg, M. Childhood functional gastrointestinal disorders: Child/adolescent. Gastroenterology 2016; 150: 1456-1468.
• Williams, L & Wilkins. Evaluation and treatment of constipation in infants and children: Recommendations of the North American Society for Paediatric Gastroenterology 2006; 43: 1-13.
• Tabbers, M, DiLorenzo, C, Berger, M, Faure, C, Langendam, M, Nurko, S, Staiano, A, Vandenplas, Y & Benninga, M. Evaluation and treatment of functional constipation in infants and children: Evidence-based recommendations from ESPGHAN and NASPGHAN. Journal of Pediatric Gastroenterology and Nutrition 2014, 58 (2): 258-274.
• Singh, C & Frances, C. Paediatric constipation: An approach and evidence-based treatment regimen. Australian Journal of General Practitioners 2018; 47 (5): 273-277