Paediatric constipation

WHAT IS IT?
- Difficulty or straining when passing stools.

- Pain when passing stools.

- Reduced frequency of passing stools (normal frequency depends on the individual, but anything from three times a day to once every other day is common).

- 5-10 per cent of children are thought to have constipation (Leung et al, 1996).

WHAT CAUSES IT?
- Lack of fibre in the diet.

- Insufficient fluid intake.

- Holding stools in: this can be for a number of reasons, including pain in passing a previous stool; painful anal conditions (anal fissure); dislike of unfamiliar or smelly toilets; and emotional problems.

- Medical conditions such as an underactive thyroid, Hirschsprung's disease, rare bowel disorders or an allergy to cow's milk.

- Medicines, such as some cough preparations can cause constipation as a side-effect.

- Battles over potty training can cause constipation in some children.

COMPLICATIONS
- Build-up of hard, large stools.

- Enlarged rectum.

- Faecal impaction.

- Faecal incontinence, as the more liquid stools bypass the impacted stool and leak out. This may be mistaken for diarrhoea, and the child has no control over it.

PREVENTION
- High-fibre diet: many children are fussy eaters and may not accept fruit or vegetables. The following may be acceptable: baked potato with baked beans; vegetable soups with bread; dried apricots or raisins as snacks; porridge for breakfast.

- Plenty of liquids: squash and fizzy drinks can fill children up, making them less likely to eat fibre-containing foods, so they should be encouraged to have water as their main drink.

- Regular toilet habit: the child should be encouraged to adopt a regular toilet habit - after breakfast, before school or nursery, is often the best time.

- Do not rush the child when he or she is using the toilet.

TREATMENT
- High-fibre diet with plenty of liquid is the first-line treatment.

- Laxatives may be required if diet does not work, or the child has severe constipation or a large impacted stool.

- If constipation is chronic it is essential to achieve colonic evacuation before starting maintenance laxative therapy.

- Laxatives are usually required for several months. They are used to clear impacted stools; encourage the child to go to the toilet more regularly; enable the enlarged rectum to return to normal size.

- Laxatives may be used in combination. There are three types of laxative: stool softeners; bulk-forming agents; stimulant laxatives.

REFERRAL
- Referral to a paediatrician may be required if: constipation is severe and intractable; Hirschsprung's disease is suspected; there is severe family distress; there is blood in the stool and/or anal pain after six weeks of treatment; constipation does not resolve after three months of treatment.

- Referral to a child psychiatrist may be necessary if there is evidence of psychological disturbance.

- Referral to a dietitian may be helpful if the child experiences major dietary problems.

WEBSITES
Digestive Disorders Foundation: www.digestivedisorders.org.uk/leaflets/constip.htm

Patient UK: www.patient.co.uk/showdoc.asp?doc=23069146

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