Constipation is one of the most common disorders which can occur in children of all ages, affecting up to 30% of children worldwide. It is particularly frequent during potty training and in younger school-aged children.
A child is considered constipated when there is decreased bowel frequency and/or hard stools; or if babies or children are very uncomfortable or manifest behaviour changes when passing stool.
Normally, infants and children have one to five bowel movements (BM) per day, ideally one BM after each meal, which should be easy to pass and well formed not pellet-like or mushy. There should'nt be any blood, mucus or undigested food in the stool. Breastfed babies tend to have less frequent poops because breastmilk is highly absorbable and there is much less residue to excrete.
Childhood constipation is divided into two broad categories
Functional constipation: without an underlying organic cause
Organic constipation: due to an underlying organic cause or an anatomic malformation or abnormality
A history and physical exam are usually sufficient to distinguish between functional and organic constipation. History taking includes investigating onset, delayed meconium passing after birth, frequency/consistency and stool size, pain or bleeding with bowel movements, abdominal pain, fecal incontinence, withholding behaviour and recent stressors or changes in normal routine. The presence of voluntary stool withholding behaviors supports the diagnosis of functional constipation.
SIGNS OF CONSTIPATION
Signs of Constipation Include One or More of the Following
Infrequent bowel movements
Hard, dry and painful-to-pass stools; clogged toilet due to hard stools
Nausea or vomiting, decreased appetite
Blood in stools surface caused by anal fissure (due to hard stools)
Liquid or clay-like stool in underwear (due to hard stool backed up in rectum)
Avoidance of having a BM for fear it will be painful
COMMON CAUSES OF CONSTIPATION IN CHILDREN
Early potty training: may lead to ‘withholding stool’ and ignoring the urge to have a bowel movement.
Voluntary Stool withholding: contracting anal sphincter or gluteal muscles (hiding in a corner and rocking back and forth or fidgeting are often signs) leads to dried, hardened and larger stools which become difficult and more painful to expel. This is often caused by an unwillingness to stop playtime, for fear of painful BM, or because of unfamiliar, unclean or lack of accessible toilets.
Diet: Insufficient fiber or fluids or consumption of constipating foods (cow’s milk & cheese in particular).
Changes in routine: school schedule, travel, illness, stressful events may affect bowel movement.
Medication such as cold remedies, pain medicines and antidepressants may contribute to constipation.
Family History: genetic factors may also be contributors to constipation.
Medical disorder: though rare, digestive, intestinal or neurological conditions may be underlying causes.
NATURAL WAYS TO HELP RELIEVE CONSTIPATION
Breastfeeding is the most important step to avoid constipation during the first six months of life. A study conducted in Brazil in 2002 found that formula-fed infants were 4.5 times more likely to develop constipation than breastfed infants.
High fiber healthy diet rich in vegetables, whole grains and fruits (ex. oats, beets, flax seeds, prunes, apricots) is also very important. Fiber absorbs water and bulks up the stool which makes it softer and easier to pass. A fiber intake of 0.5 g/kg body weight (to a maximum of 35 g/day) for all children is the American Academy of Pediatrics’ recommendation.
Non-absorbable carbohydrates like sorbitol found in prune, pear and apple juice can increase water content in stools as well as frequency of BM. 2 oz per day is an average dose, it can be diluted in water
Flax seeds: ¼ to ½ teaspoon of ground flax seeds mixed in child’s food one to three times per day.
Avoiding constipating foods, food allergens and food sensitivities. ex. Dairy products, white sugar and simple carbohydrates, excessive protein.
Ensure adequate water intake to optimize hydration as well as to make stools easier to pass.
- Breastfed babies, up to six months of age, receive all the fluids needed from breast milk if the mother is well hydrated.
- Formula-fed babies also receive adequate amounts of water from their formula
Babies may begin drinking water from a bottle after six months of age. It is very important to ensure proper hydration particularly during the summer
Children older than three years should have clear urine, if yellow, they need to drink more water
Lemon juice in warm water: lemon juice contains many minerals and vitamins which along with the warm water helps stimulate peristalsis (the contractions of the intestinal muscles).
Warm bath with 2 tablespoons of baking soda for child to soak in and relax for 10- 15 minutes.
3. Behavior Modification for Bowel Retraining
A routine toileting schedule is one of the most important steps to help your child develop a conditioned reflex for defecation at the same time each day.
Regular toileting for 3 to 10 minutes within one hour after meals combined with a reward system of praise; there should be no punishment or displeasure for not stooling during the toileting time.
Positioning to improve bowel movements: a footstool in front of toilet to support legs will help increase intra-abdominal pressure and facilitate excretion.
Regular physical activity also supports a healthy digestive system and regular bowel movements.
4. Abdominal Tuina massage stimulates peristalsis and is safe to use in newborns, infants and children. Make sure room is warm and that your hands are also warm and clean with trimmed fingernails. Apply gentle pressure on the child’s abdomen with four fingers and rub circles in a clockwise direction around the belly button. This promotes proper digestion and elimination and is also useful for abdominal pain. For infants up to 2 years of age complete 100 circles, 2 to 5 years 200 circles and 6 to 12 years 300 circles. Applying warm sweet almond oil or castor oil will make it more pleasant and avoid chaffing (adapted from http://www.robinraygreen.com/pediatric-tuina-massage-for-constipation/)
5. Acupuncture and Acupressure
Several clinical trials and studies have found acupuncture to be effective in the treatment of chronic constipation in children. According to Dr. Daniel Hsu, who practices acupuncture in New York City, acupuncture helps calm the nervous system and restore normal bodily functions including defecation. If you would like to start with acupressure before consulting a licensed acupuncturist the following acupressure treatments can be performed following the same general guidelines as the abdominal Tuina massage both with respect to preparation and number of repetitions. (for more detailed instructions, images and videos: http://www.robinraygreen.com/pediatric-tuina-massage-for-constipation/)
Acupressure Points to help with bowel movements
Line pressing on index finger: using your thumb, rub in a line from the junction of the thumb and index finger all the way to the tip of the index finger, lift and repeat. This regulates the large intestine and promotes BM
Circle pressing on palm of hand: using your thumb, rub palm of child’s hand in a clockwise direction around the central depressed portion in the middle of the palm. This helps harmonize the organs networks according to Traditional Chinese Medicine
Triple energiser 6 (TE 6) Bo Yang Chi: locate point in the middle of the forearm, a distance of three fingers above the wrist and knead it to help relax the bowels making elimination easier
Stomach 36 (ST 36) Zu San Li: measure the equivalent of your child’s four fingers below the kneecap (you will feel a little natural indentation) and rub this point gently
Line pressing along the lumbar spine and sacrum: using index and middle fingers rub a line down the lumbar spine to the end of the sacrum. Lift and repeat
Pinching pulling on the lumbar spine: start at the sacrum gently pinch the muscle tissue between thumb and forefingers as you continue to more your thumbs forward up to the lumbar spine. Lift and repeat. This helps stimulate the acupuncture points associated with the bowels
6. Magnesium citrate or magnesium hydroxide exerts a laxative effect by relaxing the bowel and increases water in the intestines. Dosage should be strictly based according to age and/or weight. Check with your child’s healthcare provider before using magnesium, there are rare cases where it may be contraindicated and improper dosing may lead to magnesium poisoning in infants
Senna: available in both capsules and teas, this herbal laxative comes from the leaves of the Senna plant. It works by increasing the peristalsis of intestinal muscles. Always check with your child’s healthcare provider before using any senna products
Ginger helps with digestion and BM; it is known as a ‘warming herb’ which can help speed up slow digestion and promote bowel activity. Available as a tincture or tea.
Bitter Herbs stimulate peristalsis, these include dandelion, ginger, chamomile, marshmallow root, licorice root. Most are readily available as teas.
There is no conclusive evidence regarding the use of probiotics in the treatment of constipation in children. However, the presence of dysbiosis in the gut may contribute to functional constipation and several trials have found an improvement in stool frequency and quality with supplementation
Bifidobacterium has been found to soften stools, improve defecation frequency and abdominal pain according to one crossover double-blind trial
Lactobacillus GG was found to significantly reduce the frequency and severity of abdominal pain in one trial out of the University of Michigan in collaboration with the CS Mott Children’s Hospital in Michigan
NOTES ON LAXATIVE USE AND SAFETY
Over-the-counter medications may be needed to address your child’s constipation. Always check with your child’s doctor for proper dosage and advice prior to using them.
Miralax is a very effective treatment for constipation often prescribed by pediatricians. But it has not been approved for use in children. Polyethylene glycol 3350 (PEG 3350), the active ingredient in Miralax, is supposedly non-toxic and non-absorbable. However, FDA testing on certain batches of Miralax found small amounts of actual antifreeze: ethylene glycol and diethylene glycol. Furthermore, intestinal absorption of Miralax has never been studied in children.
The FDA has received reports of psychiatric problems linked to the use of Miralax (tics, tremors and obsessive-compulsive behavior). More studies are needed to evaluate whether there is some systemic absorption of PEG 3350 occurring and to determine safety as well as any long-term consequences which may be associated.
USE OF SUPPOSITORIES AND ENEMAS
Suppositories and enemas may be necessary when fecal impaction. They will help loosen stools prior to initiating other therapies. Check with your child’s healthcare provider prior to using either of these methods which include:
Saline enema or phosphate soda enema: care and caution must be exercised while administering enema to avoid causing pain or injury.
Lactulose and glycerine suppositories. the general glycerin suppository dosing is as follows:
- ½ to 1 infant suppository for children under 6 years of age
- 1 adult suppository for children over 6 years of age
WHEN TO IMMEDIATELY SEE A DOCTOR
Childhood functional constipation is very common and usually easily resolved by natural and/or conventional approaches. However, in rare cases constipation can be a symptom of an underlying medical condition which needs to be addressed by a qualified physician. Red flags suggesting an organic cause of constipation in children and which necessitate a prompt visit to your child’s doctor include:
Delayed passing of meconium after birth (more than 48 hours)
Onset of constipation before one month of age
Failure to thrive
Explosive stools accompanied by intermittent diarrhea
Severe abdominal distension and pain
Constipation accompanied by fever
Occult blood in stools
Vomiting accompanied by fever and ill-appearance
No response to conventional treatments
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