Constipation :: Nationwide Children's Hospital

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Constipation – PediaCast 292

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Constipation or incomplete bowel emptying is a very common contributor to urinary problems.

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Bowel Management Clinic

While all of our GI doctors and nurse practitioners are skilled in taking care of children with constipation, some children benefit from being seen in our Bowel Management Clinic (BMC). The BMC involves frequent follow-up with a nurse practitioner to manage the medical aspects of your child's problem, and with a behavioral specialist to ensure that the medical treatment is as effective as possible.
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Percutaneous Cecostomy

Nationwide Children's is unique in its approach to treating children with retentive fecal incontinence.
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Learn more about treating Constipation and Fecal Soiling

Constipation

Many children have constipation at one time or another. Minor changes in daily routine may cause it. Being away from home, changes in eating, drinking or activity may cause constipation. It is very common for children to avoid having a bowel movement at school, which can lead to constipation. Most of these things will not last long. They are easy to correct and do not result in long-term health problems.

Constipation means different things to different people. It can be defined as:

  • More than three days between bowel movements

  • Stools that are large, hard and painful to pass

  • Incomplete bowel movements and stool backs up in the bowel despite daily bowel movements

Constipation can be linked to:

  • Stomach aches

  • Decreased appetite or eating

  • Feeling of being “full”

  • Small amounts of blood on the toilet paper or on the outside of the stool

  • Stool leaking into the underwear (encopresis or soiling)

  • Repeated urinary tract infections

Constipation does not cause:

  • Head aches

  • Bad breath

  • Learning problems

  • Back-up of poisons into the bloodstream

  • Rupture of the colon or intestine

Encopresis is the accidental loss of control of the bowels. This usually results in stool staining the underwear. Encopresis occurs in children 4 years of age or older, under this age the child may just not be toilet trained.

Having clear answers to your questions is often the first and most important step when your child has been diagnosed with constipation. We have compiled answers to the questions we hear most often about constipation. To read our Q&A, simply click on each of the questions below.


Childhood Constipation Deemed Significant Health Issue
According to new research conducted at Nationwide Children’s Hospital, the burden of illness in children suffering from constipation, and the costs associated with this condition, are roughly of the same magnitude as those for asthma and attention deficit-hyperactivity disorder (ADHD).  View video 

 


Meet Our Patients


 

Kris

Kris, now 16, developed encopresis at age 4. The current sophisticated motility testing was not available at Nationwide Children's Hospital until Kris was 11. At that age, he underwent extensive motility testing before having a cecostomy irrigation catheter placed in his abdomen. Prior to that time, Kris was placed on a variety of medications and treatments. He was experiencing soiling every day, skin breakdown, abdominal pain and flatulence. Once the cecostomy tube was placed, Kris eventually developed a routine bowel pattern and most of the other symptoms disappeared. His intestinal tract eventually gained enough muscle strength that he no longer required the irrigation catheter. It was removed at age 16 and he is now being maintained on medication only. One challenge for Kris and his parents has always been to help support his self-esteem and self-image. He has participated in counseling over the years. His mother held classes to tell his teachers and classmates about Kris’ challenges. Educating those in Kris’ life about encopresis and the treatment involved has been a key point in his success.

  [read more...]

Even during the most challenging times, Kris has remained very active. He is very athletic and has played volleyball, basketball and baseball, and he is a weight lifter. He is socially active and does well academically. His positive attitude, along with the support of family and friends, has been instrumental in his progress towards normalcy in his life. We are very proud of his attitude and outlook.

Contact Information:
Stephanie
Italianbabe78@columbus.rr.com

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The stool pattern varies with the age and diet of the child. Infants who are breast-fed may vary from several watery or loose stools a day to going up to 10 days without a stool. By one- to three-months of age, their stools often become pasty and less frequent. Formula-fed infants often have pasty stools one to three times a day. Some formulas such as Carnation Good Start, Nutramigen, Pregestimil and Alimentum may cause loose stools. By 1 year of age, most children are passing formed stools at least once every one to three days.

Infants commonly cry, fuss, turn red and appear to be working hard for several minutes when passing either stool or gas. If the infant is growing well and the physical examination is normal, this is most likely a behavior pattern and not a disease. This will improve as the infant “learns.”

Toddlers and children normally pass stools from three times a day to every three days. The form and color of their stools may vary from day to day. Changes in the color of the stool (unless it is red, black or white) do not mean there is a problem. It just means that the normal colon bacteria are acting on various food dyes. Sometimes even red, black or white stools can just be a result of what the child has been eating or drinking, such as a lot of red juices or jello.

Digestion starts in the stomach where food is mixed with digestive juices. Food slowly leaves the stomach and passes into the small intestine where it is mixed with more fluid. It then passes into the colon as a watery liquid after nutrients have been absorbed. The job of the colon is to slowly absorb water. Soft, formed stool enters the rectum and stretches it, giving the urge to have a bowel movement. To have a bowel movement, we must consciously relax the muscles that are holding the stool in and then push the stool out.

If the child holds back stool or cannot have a bowel movement over several days, the rectum fills up with stool. Over time this stretches the muscles of the rectum and makes them less able to push out stool. The child looses the urge to pass a bowel movement. Holding stool in the rectum also allows more time for water to be removed. This can make the stool hard, dry and painful to pass.



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Chronic constipation (lasting over a long period of time) is not usually caused by medical problems. A “blockage” in the colon does not cause it either.

Toddlers often try to hold in their stool after having a painful bowel movement. They often cross their legs and become rigid. They are determined not to have another painful experience and can often hold their bowel movements for days. This, of course, leads to large, hard bowel movements. This experience convinces them that having a bowel movement is something to be avoided. They may sometimes seem to be trying to have a bowel movement when they are actually trying not to go. Fissures and other painful conditions of the anus can also lead to this problem.

Children who are going through toilet training may not want to take the time out from play to go to have a bowel movement. They may also be afraid to use a bathroom other than the one they are used to. Many children do not want to have a bowel movement at school or a new daycare. If you anticipate these problems and deal with them early, you can help resolve the constipation that results from holding in stool in these situations.

Some children have trouble learning to relax their bottom as they try to push stool out. These children may push and hold at the same time, making it difficult to pass stool. Children usually can’t hold in stool and blow at the same time. Having a child blow a pinwheel or party noisemaker while trying to stool can help them learn to relax their bottom.

Some children have slow movement of their colon. This gives the colon more time to remove water from the stool, making it hard, dry and difficult to pass. This may improve with time.



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Although most children do not have a serious medical reason causing their constipation, your doctor or nurse practitioner will consider these during your child’s history and physical examination. Most children will not need testing beyond a complete history and physical exam to evaluate their constipation. Medical conditions that are rarely related to constipation include:

  • Small or abnormally placed rectums

  • Abnormal nerves in the rectum (Hirschsprung’s disease)

  • Problems with the spinal cord

  • Diseases of muscles and nerves

  • Low thyroid

  • Kidney problems leading to dehydration



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Children who have chronic constipation gradually develop a stretched rectum. The stretched rectum then becomes filled with a stool plug. Over time the stretched muscles of the rectum cannot push all of the stool out of the rectum. Liquid stool seeps down around this stool plug and can seep out onto the underwear without the child being aware that there is stool in the rectum or that they are about to soil. This is frustrating and embarrassing for both the child and the family. While treatment can help the child solve the problem, it is a chronic condition that has taken time to develop and will take time to correct. Relapse often occurs if treatment is stopped too soon or withdrawn too quickly.



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Treatment for constipation and soiling has three phases – clean out, maintenance, and reestablishing toileting behaviors.

Clean-Out Phase
The clean-out phase is designed to clear the stool plug out of the colon. This can be done with medicines taken by mouth, enemas and suppositories given in the rectum, or a combination of both. Small children who have holding behaviors because of painful bowel movements or fear of passing stools may do better with medicines given by mouth. Although gentle enemas are effective, they may make the child even more fearful.

Hard stool is very difficult and painful to pass. Your child’s clean-out phase may be started with large doses of mineral oil to soften the stool. Mineral oil is not absorbed and gradually seeps through the hard stool and softens it. It may take several days of mineral oil to soften a large amount of packed stool. Mineral oil is dangerous only if it gets in the lungs. This is why it should not be given to infants or children who have trouble swallowing. Mineral oil can be given by enema or by mouth. Since mineral oil has an oily feel to it, most children will take it better when it is mixed with another food. Some of the easier ways to give it include putting it in milk shakes, pudding, applesauce, ice cream, chocolate milk and in juice “slushies.”

Once your child’s stool is soft, your doctor or nurse practitioner may suggest that you add other medicines by mouth or rectum. It is very important to remove the entire stool plug during the clean-out phase or the next phase will not work as well.

Maintenance Phase
Once the clean-out phase is complete, your doctor or nurse practitioner will tell you what medicine your child will take every day. Small children who are afraid of painful bowel movements will receive medicine to soften their stool. Mineral oil is very effective for this, because it helps the stool slide out more easily. Fiber, which helps keep water in the stool, may also help wit this. The richest source of fiber is usually found in breakfast cereal. To find how many grams of fiber your child needs each day, add 5 to your child’s age. For example, a 3-year-old child needs about 8 grams of fiber every day.

Some laxatives are salts that hold water in the stool. Examples include Milk of Magnesia and Miralax. Other laxatives work by fermenting sugars and producing gas. These include apple juice, lactulose and maltsupex. These are not very good treatments, because they may cause gas cramps. Other laxatives may cause stretched and weakened muscles to contract. These include senna and bisacodyl. Your doctor or nurse practitioner can suggest the treatment that will work best for your child. This chart lists some of the pros and cons of various treatments:

Medication

Action

Advantages

Problems

Mineral Oil

Lubricates

Cheap; stools easy to pass

Do not use with infants; Oily Feel

Milk of MagnesiaTM

Holds Water

Cheap; stools easy to pass

Taste

Senna

Stimulates

Strengthens muscle

May cause cramps

Bisacodyl

Stimulates

Strengthens muscle

May cause cramps

Maltsupex

Produces Gas

None

Cost

Lactulose

Produces Gas

None

Cost

Miralax TM

Holds Water

No taste

Cost

Treatments That Should NOT be Used in Children:

  • Fleets Phospho-Soda enemas should not be used in children. They can severely disturb electrolyte balance when held in the colon.

  • Milk and molasses or a lactulose enema can cause a distended (puffed out) belly above a stool plug with possible tearing. Therefore, these are not recommended for children with chronic constipation.

Reestablishing Regular Toileting Behaviors
Once your child is having soft, comfortable bowel movements on a regular basis, the next step is to get their regular toileting schedule back on track. Many times, this routine has been disrupted due to the child’s fear of having a painful bowel movement, or because they are less likely to sense when they need to use the toilet for a bowel movement.

Our team includes behavioral specialists who provide additional care for patients with encopresis. These specialists help your child:

  • Get a regular toileting routine started

  • Have less anxiety around having a bowel movement

  • Reduce their stool withholding behavior

  • Have less conflict with their parents over the problem

  • Feel that they are part of the treatment team

You and your child can see the behavioral specialist for separate appointments or as part of a visit to our Bowel Management Clinic. Your doctor or nurse practitioner will help you decide which service will be right for you.



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Your child should be on enough medicine to prevent a stool plug from forming. Children on the proper therapy usually have one to three loose to very soft stools every day. If children on therapy go two to three days without a bowel movement, their therapy should be increased. Soiling usually means a stool plug rather than too much medicine.



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Chronic constipation usually develops over months or years. Most children need at least six months of therapy and having regular bowel movements before they can be weaned from the therapy without a relapse. Changes in routine that can cause relapse include travel, change in diet or the start of school. These “slips and setbacks” can be taken care of more easily if they are dealt with promptly. They should not be seen as failed therapy.



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Mild constipation may be treated with diet changes. Increased fiber may soften stools. Sugary drinks that ferment (such as apple and fruit juice) may be used as well. Prune juice has the advantage of fiber as well as natural senna. Extra water or fluids generally don’t reach the colon.

Children with soiling or more severe constipation usually require medication. However, making changes in your child’s diet at the same time may help wean them from medications more quickly. Getting children, especially toddlers, to eat the diet we would like may be difficult, but the extra effort will be rewarded with happier children.



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700 Children's Drive Columbus, Ohio 43205 614.722.2000