Original Post on 5 Oct 2007 (Edited)

Constipation is the passage of stools with a frequency much less than usual or passage of hard and difficult to pass stools. Different children may have different “normal” frequency of passing stools and may range from soft stools passed every 3-5 days to passage of soft formed stools a couple of times a day.

Is constipation an illness?
Constipation is not an illness per-se. It is rather a symptom of an illness or condition.

What are the common causes of constipation in children?
By far the most common cause of constipation is the lack of dietary fiber. Consumption of highly refined and processed food leads to formation of compact and hard stools because of lack of fiber. Fiber when present leads to formation of softer and less compact stools.
Poor toilet training habits are also increasingly responsible for cases of constipation in children. Inadequate toilet training causes infrequent emptying of the bowels which in turn leads to desiccation of the fecal mass in the rectum to form hard stools. On the other hand, overly vigorous toilet training practices may also lead to constipation. Children may resent having to go to the toilet and may forcibly hold their bowels leading to inadequate and infrequent emptying and formation of hard stools.
Less frequently, constipation may be a symptom of an abnormal intestine or hormonal imbalance. These need to be specifically ruled out in very young children with very severe constipation.

Strategies and concepts in the management of constipation:
Softening stools: There are several ways of ensuring softer stools. In mild cases of constipation simple stool softening measures may be highly effective by themselves.

• Natural stool softeners: Dietary fiber from vegetables and fruits are very useful. The fiber in vegetables gives shape and less compactness to the formed stools which prevents constipation. Certain fruits and fruit juices contain non-absorbable osmotic sugars like Sorbitol. These sugars cause the stool to retain larger volumes of fluids making them softer and easier to pass. Juice of Pears, Prunes and Apple contain significant amounts of Sorbitol and are very helpful while managing constipation.
• Medical stool softeners: There are several agents available as stool softener and many practitioners have their favorites. Lactulose is one such agent commonly used in Maldives. It is a safe and effective compound.

Cathartics: These are agents that cause forced bowel movements and evacuation. These are generally not recommended in children and may be counter-productive. These should be use only under medical guidance.

Enemas and rectal stools softeners: stool softening and lubricating agents may be given per rectally in cases of severe constipation or when stools are very hard and painful to pass or when there is pre-existing rectal or anal injury from constipation. These are sometimes very helpful but are not recommended for routine use because of their invasive nature. These too must be used only under medical guidance.

Improving toilet habits: regular bowel emptying to prevent retention and desiccation is a helpful strategy in children who have severe constipation. These will however only be successful along with stool softening strategies. One concept involves aggressive stool softening measures for a few weeks followed by gradual toilet training routine. The success depends on the child accepting use of toilet bowls as a safe and pain free way of emptying bowels.

Strategies I commonly use:
Mild constipation: If the problem is of acute onset and very mild I usually prescribe a short (about a week) course of oral stool softener (mostly Lactulose) followed by changes to diet to include fiber-rich vegetables (like green leafy vegetables) and packed fruit juices (mostly apple, pear and prune juice). This is usually very effective and the feedback I have received from parents has been very positive.

Acute severe constipation (Especially when a child has not made a stool for several days and has hard and difficult to pass stools): I mainly concentrate on minimizing discomfort and preventing the acute constipation changing to a chronic one. My strategy involves aggressive stool softening measures for about a week. They mainly include use of multiple daily doses of an oral stool softener (like Lactulose) along with rectal stool softeners (like glycerine suppositories) for the first few days of treatment. I tell parents to insert the suppositories and to leave the child be, not making him go to the toilet. The reason for this is that I want to give time for the glycering to lubricate and also soften the stools before the child is made to pass stools. I do this because I believe that the child should have minimum discomfort when passing the long delayed stool. Once stools are being passed regularly I would cut down on the number of times oral stool softener is used to about once a day (mainly just before bed time) for another week. During this second week of treatment I would ask the parents to concentrate on introducing fiber-rich food and stool softening fruit juices and to ensure toilet training measures are in place.

Chronic severe constipation: In addition to the management discussed for acute severe constipation, I would usually investigate these children for other less common causes of constipation such as intestinal anomalies and hormonal imbalances. The management strategies would also concentrate on effective toilet training practices. It is absolutely essential that toilet training be initiated after stool softening strategies are in place and working effectively. I believe in a slow, gradual introduction of toilet training. I would sometimes begin by asking the parents to get the child to simply sit on the toilet seat while fully clothed. They don’t have to pass stools. This is done to remove “potty-fear”. Once this is achieved I would ask the parents to get the kids to sit on the potty just wearing their nappies or under garments. They don’t have to pass stools. One this is achieved, over the next few days I would ask the parents to get the child to sit on the potty undressed and ready to pass stool. Allow them to pass stool if they would like to, it is not compulsory. However, whether they pass a stool or not I would ask the parents to wash their bottoms before allowing them to leave the toilet. At this point many of the kids would have realized that they need not fear passing stools. Passing the softened stools does not hurt at all. That alleviates their fear of the potty and passing stools.

One very common misconception among parents and some medical personnel is that constipation can be resolved just by getting the child to drink more water. While it may be true that drinking very little water could lead to some hardening of stools drinking extra amounts of water has not been found by research to be an effective strategy in managing constipation. The extra water is absorbed from the gut and passed out in the urine and has little or no effect on stools.