Constipation week – Day 5 – Advice and information for parents

Cite this article as:
Angela Clarke. Constipation week – Day 5 – Advice and information for parents, Don't Forget the Bubbles, 2014. Available at:
https://doi.org/10.31440/DFTB.5639

Education of the child and family of the physiology of constipation and mechanism of overflow soiling is important.  Below are some tips, tricks, and generally things not to forget.

See our other Constipation Week posts

 

What other recommendations can I give?

You can mix the PEG 3350 with other fluids:

  • Whichever Macrogol PEG you use, you can then mix this with cordial, juice, milk or pretty much whatever you like, to disguise the taste.

Dietary advice:

  • Advise the parent to increase fibre and water intake in their child’s diet.
  • Dietary modifications can make a huge impact. Fibre such as beans, whole grain, cereals and fresh fruit and vegetables are good for improving the symptoms. Foods without fibre (cheese, meat, processed food) should be limited. Plenty of fluids will help keep the stool soft but milk should be limited to less than 500ml per day.
  • It may be worth referring the child to a dietician for further advice.

Exercise:

  • Daily exercise is recommended to improve bowel motility. A 30 minute walk each day can improve regularity of bowel motions.

Use a foot stool:

  • The best position for defaecation is squatting, as there is better alignment of the recto-anal angle.
  • By placing a stool under the child’s feet, placing the knees above the anus, you are improving the recto-anal angle, thus relieving any obstruction to stool outflow (Sikirov).

correct positioning

Positive reinforcement:

  • For most children with constipation, going to the toilet has now become a negative experience.  It is important to encourage parents to give positive feedback to the child when they pass a stool and not to berate them if they were unable to.
  • Sitting on the toilet should not be an unpleasant experience so encourage the parents to let them read a book, listen to music, or play a computer game.
  • Reward systems are a good way to aid this positive reinforcement. A good suggestion is using a star chart or bowel diary, where the child gets a sticker every time they sit on the toilet and an extra sticker when they pass a stool. The child can then be involved in deciding a reward for a certain number of stickers gained.

Scheduled toileting:

  • Teach the parents about the gastro-colic reflex – i.e. increased motility of the colon in response to stretch in the stomach after eating.
  • Therefore, the most likely time for the child to pass stool approximately 15-20 minutes after food (Lowery et al)

If behavioural techniques fail, consider referral to a paediatric occupational therapist for further advice.

 

Where can I find a good information sheet?

Good information sheets:

Good websites to refer parents to:

References

Bracewell M, Bunce N.  Movicol Paediatric Plain: A Treatment for Constipation in Children.  Sussex Community NHS.  2009 July. https://gp.westernsussexhospitals.nhs.uk/wp-content/uploads/gpsiteweb/Leaflet11movicol-AssetID=354390&type=full&servicetype=Attachment.pdf

Sikirov BA. Primary Constipation: An underlying mechanism.  Medical Hypotheses. 1989 February;28(2):71-73.

Lowery S, et al. Habit Training as Treatment of Encopresis secondary to Chronic Constipation.  Journal of Pediatric Gastroenterology & Nutrition. 1985 June;4(3):397-401.

 

Understanding constipation

Cite this article as:
Tessa Davis. Understanding constipation, Don't Forget the Bubbles, 2014. Available at:
https://doi.org/10.31440/DFTB.5436

It may seem mundane, but successfully managing constipation can make a massive difference to the lives of families. Although it’s all about faeces; it can lead on to other issues including pain and social embarrassment. Time spent managing this can have a knock on effect on the whole family, as well as the patient.

See our other Constipation Week posts

What is normal?

Normal bowel movements vary with age:

AgeStools per dayMouth to rectum time (hrs)
<2 years<216
<3 months2 to 38.5
0-1 week4-
  • The first stool is normally passed within 36 hours of birth
  • Breast-fed infants can have a huge range of normal frequency from 10 stools per day to 1 stool every 10 days
  • Formula-fed infants tend to have more bowel actions than breast-fed infants

As stool goes round the colon and out to the rectum, water is reabsorbed. So by the end, it will be smaller and harder than it was when it was at the appendix (which is why colostomy bags initially have a watery output). Hard poo is sore to pass so children often don’t want to pass it at all. Therefore it collects, and stays in the bowel longer getting more and more impacted. If stools takes a longer time to pass through the colon, it will become harder and drier. So the treatment is based around adding water to it, and getting things moving.

There are 3 periods when children are prone to developing constipation: the introduction of solids; toilet training; and starting school. These all have the potential for defecation to be an unpleasant experience, prompting the child to consciously or subconsciously avoid repeating it.

This painful defecation can then leading to avoidance of defecation which results in stool accumulation in the rectum. The stool becomes harder and therefore more painful to pass. Chronic rectal distension leads to relaxation of the internal anal sphincter and semi-solid stool leaks or soiling. Finally, the rectum is unable to generate enough pressure to pass stool.

Causes can be split into functional and organic.

Functional
This is an umbrella term for difficult, infrequent, or incomplete defecation with no structural or biochemical cause. It accounts for 95% of constipation.

Organic
This is constipation associated with an organic condition which accounts for 5% of constipation. Organic causes are anatomic malformations; metabolic; gastrointestinal; neurological; connective tissue disorders; drugs; miscellaneous.

There are several mechanism for this:

  • Infant dyschezia – straining with soft stools in a less than 6-month-old
  • Functional constipation in infants and preschool children – pebble-like stools less than twice a week
  • Functional faecal retention – holding on, soiling, cramps for at least 12 weeks
  • Functional non-retentive faecal soiling – inappropriate soiling without retention, emotional issues

Reservoir constipation is where the stools collect in the bowel and start to get larger and larger.

This is commonly seen in 5-10 year old boys.

The history is often of passing a large diameter stool every 1-2 weeks. Often because it’s painful to pass these, children can be scared to pass stools and hold them in. This causes the rectum to stretch due to pressure on the rectum. Then the nerves in the wall of the rectum stretch causing a problem with the internal sphincter. A problem with the internal sphincter means that children may be able to hold onto their stools on the journey home (using their external sphincter) but then as soon as they relax at home they will get some soiling.

These children have a numb, toneless rectum which means that they then don’t realise when it’s time to pass stools.

Reservoir constipation can occur because children are too busy to poo, find the toilets too dirty to use (or not private enough), or are scared of pain.

There are other causes of constipation too. For example, there are some psychological causes of encopresis and also some neurological causes. Any clinical examination should be careful to look for neurological signs: check for spina bifida occulta, look for any sinuses or fissures; look for a patulous anus.