Pediatric Advisor 10.0: Constipation

Children & Adolescents Clinic

Clinical Reference Systems: Pediatric Advisor 10.0
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Constipation

Description

Painful passage of bowel movements: The most reliable sign of constipation is discomfort with the passage of a bowel movement.
Inability to pass stools: These children feel a desperate urge to have a bowel movement (BM), have discomfort in the anal area, but are unable to pass a BM after straining and pushing for more than 10 minutes.
Infrequent bowel movements: Going 3 or more days without a BM can be considered constipation, even though this may cause no pain in some children and even be normal for a few. Exception: After the second month or so of life, many breast-fed babies pass normal, large, soft BMs at infrequent intervals (up to 7 days is not abnormal) without pain.

Common Misconceptions About Constipation

Large or hard BMs unaccompanied by any of the conditions just described are usually normal variations in BMs. Some normal people have hard BMs daily without any pain. Children who eat a lot of food pass extremely large BMs. Babies less than 6 months of age commonly grunt, push, strain, draw up the legs, and become flushed in the face during passage of bowel movements. However, they don't cry. These behaviors are normal and should remind us that it is difficult to have a bowel movement while lying down.

Cause

Constipation is often due to a diet that does not include enough fiber. Drinking or eating too many milk products can cause constipation. It's also caused by repeatedly waiting too long to go to the bathroom. The memory of painful passage of BMs can make young children hold back. If constipation begins during toilet training, usually the parent is applying too much psychological pressure.

(See Toilet Training Basics .)

Expected Course

Changes in the diet usually relieve constipation. After your child is better, be sure to keep him on a nonconstipating diet so that it doesn't happen again.

Sometimes the trauma to the anal canal during constipation causes an anal fissure (a small tear). This is confirmed by finding small amounts of bright red blood on the toilet tissue or the stool surface.

Home Care

Diet treatment for infants less than 1 year old
For babies less than 2 months old, try giving 1 teaspoon of dark Karo syrup twice a day. Give fruit juices (such as apple or prune juice) twice a day to babies over 2 months old. Switching to soy formula may also result in looser stools. If your baby is over 4 months old, add strained foods with a high fiber content such as cereals, apricots, prunes, peaches, pears, plums, beans, peas, or spinach twice a day. Strained bananas and apples are neither helpful nor constipating.
Diet treatment for older children over 1 year old
- Make sure that your child eats fruits or vegetables at least three times a day (raw, unpeeled fruits and vegetables are best). Some examples are prunes, figs, dates, raisins, peaches, pears, apricots, beans, peas, cauliflower, broccoli, and cabbage. Warning: Avoid any foods your child can't chew easily.
- Increase bran. Bran is an excellent natural stool softener because it has a high fiber content. Make sure that your child's daily diet includes a source of bran, such as one of the new "natural" cereals, unmilled bran, bran flakes, bran muffins, shredded wheat, graham crackers, oatmeal, high-fiber cookies, brown rice, or whole wheat bread. Popcorn is one of the best high-fiber foods for children over 4 years old.
- Decrease the amount of constipating foods in your child's diet. Examples of constipating foods are milk, ice cream, cheese, yogurt, and cooked carrots.
- Increase the amount of fruit juice your child drinks. (Orange juice will not help constipation as well as other juices).
Sitting on the toilet (children who are toilet trained)
Encourage your child to establish a regular bowel pattern by sitting on the toilet for 10 minutes after meals, especially after breakfast. Some children and adults repeatedly get blocked up if they don't do this.
If your child is resisting toilet training by holding back, stop the toilet training for a while and put him back in diapers or pull-ups.
Stool softeners
If a change in diet doesn't relieve the constipation, give a stool softener with dinner every night for one week. Stool softeners (unlike laxatives) are not habit forming. They work 8 to 12 hours after they are taken. Examples of stool softeners that you can buy at your drugstore without a prescription are Haley's M-O, Metamucil, Citrucel, and mineral oil. Give 1/2 to 1 tablespoon daily.
Common mistakes in treating constipation
Don't use any suppositories or enemas without your physician's advice. These can cause irritation or fissures (tears) of the anus, resulting in pain and stool holding. Do not give your child strong oral laxatives without asking your physician because they can cause cramps and may become habit-forming.
Relieving acute rectal pain
If your child has acute rectal pain needing immediate relief, one of the following will usually provide quick relief:
- sitting in a warm bath to relax the muscle around the anus (anal sphincter)
- giving your child a glycerine suppository
- gently putting a thermometer in the anus for 10 seconds to stimulate the rectal muscle.
If these measures fail, use a saline enema, but only if you have your physician's approval. The normal saline enema is made by adding 2 teaspoons of table salt to a quart of lukewarm water. Do not use enemas with soapsuds, hydrogen peroxide, or tap water. They are dangerous. Your child should lie on his stomach with his knees pulled under him. The enema tube should be lubricated and inserted 1 and 1/2 inches to 2 inches into the rectum. The enema fluid should be delivered gradually by gravity, with the enema bag no more than 2 feet above the level of the anus. Your child should hold the enema until a strong need to have a bowel movement is felt (2 to 10 minutes). If you do not have an enema apparatus, you can use a rubber bulb syringe.
The amount of normal saline solution that should be given to children at various ages is:
```
 
      1 year. . . . . . . . . . . . . . . .  4 ounces 
      1 to 3 years . . . . . . . . . . . . . 6 ounces 
      3 to 6 years . . . . . . . . . . . . . 8 ounces 
      6 to 12 years. . . . . . . . . . . .  12 ounces 
      Adolescents and adults. . . . . . . . 16 ounces 
```

Call Your Child's Physician Immediately for Advice About an Enema or Suppository If:

Your child develops severe rectal or abdominal pain.

Call Your Child's Physician During Office Hours If:

Your child does not have a bowel movement after 3 days on the nonconstipating diet.
You are using suppositories or enemas.
You have other concerns or questions.