Conversations about constipation

Cite this article as:
Chris Dadnam. Conversations about constipation, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31554

Like most of you I have to deal with the issues of constipation within the ED or CAU environment and most of the time it’s not the reason the child attends the department! This can then lead to a series of awkward questions and issues that parents may ask that we need to consider in order to provide safe, useful and most of all, worthwhile advice! 

So let’s go through these questions ask issues:

1. My child has a UTI, why are you talking to me about constipation? 

This is something I get asked not only when a UTI is diagnosed but other clinical conditions including; appendicitis, bedwetting, incontinence, urinary retention, obstruction, etc…. it is important that parents understand the implications of constipation, not only from a pain and symptoms point of view but also the complications surrounding it. Indeed, many parents also struggle to understand how their child, who is rolling around in agony, is only suffering from constipation (you can literally feel them questioning your medical acumen). 

During these tough times I always mention two key points. Firstly, the fact that your bowel covers the majority of your abdomen. A build up of wind and solid matter in the bowels can bring about severe griping abdominal pain, when pressing against sensitive nerves. As it covers a lot of your abdomen, when full, it will compress other structures like your child’s bladder leading to urinary infections, incontinence and retention. The second point is that stools are like a toxin your body wants to expel, when it remains in your bowels it can get into small structures like your child’s appendix and cause it to become inflamed and that leads to appendicitis.

Also, the longer the stools sit in the colon the more water is absorbed leading to harder, solid stools. This will cause a blockage and lead to vomiting and obstruction which may require surgery. 

Once parents have a better understanding of these points they’re less likely to roll their eyes at constipation! 

2. How are they constipated, they go every day? 

This in fairness is a good question, one that used to throw me quite a bit in my early paediatric years, but let’s break it down. Constipation is not simply the length of time between going to the toilet, rather it is the build up and insufficient clearance of stools in your bowels. With this in mind, a child can go daily and pass small amounts of stool but still have a backlog of faecal matter in their bowels. Therefore also question the time spent on the toilet, straining and pain during defecation. These are all signs of constipation. If you can, ask your young patients too! 

3. They already drink plenty of fluids

Don’t let this answer fool you, explore the parents’ meaning of fluids. When we are saying it, we mean clear liquids like water and squash (preferably sugar-free), but for the parents, it’s anything from water and tea, to milk and hot chocolates. Now there is a myth that milk makes us constipated but that’s simply not the case….well not entirely. Milk is indeed a liquid and it doesn’t make us constipated but it’s thicker and takes longer to digest (hence why in surgery they stress only clear liquids 4hrs before). Milk fills up the child and so reduces their intake of solid food which will be full of fibre. 

Always remember, parents may say they’ve cut out all the milk, but this may have been substituted for milky teas and hot chocolates, so double check! 

In terms of managing the milk, appreciate the difficulty the family is about to face. Wean the milk down slowly, starting with the bottles in the middle of the day, then the morning bottle and finally the night bottle. Milk shouldn’t be stopped entirely, having a 250-500ml glass of milk daily is perfectly fine. 

4. They eat a really good diet 

Whenever I get this response, I immediately think they haven’t and 99% of the time I’m right……says a lot. 

Again, this is either due to a misconception as to what a good diet is, or they don’t think it’s an important issue so they simply brush it off with this generic statement so that they can get to the medication that will actually help. Another quick way to check is to just ask the child. They normally find it much more difficult to turn a blind eye.

I always try to tackle this in one of two ways:

Tell me what they eat?

– it’s surprising how many children don’t have breakfast or any of the three square meals a day. If they do, just add in tips when you can.

Breakfast; dried fruits in cereal (especially raisins), don’t switch the cereal completely but rather mix in an all bran, so they’re still getting their tasty favourites, but now with added fibre. Toast – if it’s white bread, freeze it; it’ll keep longer and by placing it straight into the toaster means that the strands of carbs, fats and protein are bound together and form fibre.

Lunch; Try to include salad into sandwiches. If the parents say they don’t like salad then how do they expect their children too! Encourage healthy eating in the parents as well, to form positive connotations for their kids.

Dinner; any sauce can hide a multitude of veggies if blended or chopped fine enough – so get them cooking and where possible get them to encourage their kids to join in. If they cook it themselves, they’ll appreciate the food and, for some reason, enjoy it more……probably a labour of love! And it’s a great time to leave out and pick on a bowl of fresh berries or grapes, the more accessible things are the more they get eaten.

Do they eat all their fruit and vegetables?

This again leads to a classic ‘Yes’ response – which falsely reassures a lot of healthcare professionals. In truth, it’s a vague and rather inadequate question to ask. If I told you that my child eats peeled apples and pears, has a glass of orange juice and then eats loads of veggies which I boil until soft… It might make you think twice about the goodness they’re actually getting.  So I always ask – Do they eat the skins of the fruit and vegetables? How do you prepare them? The skin of most fruits and vegetables holds the majority of fibre along with different vitamins and minerals required. In all honesty, if you are peeling apples and pears, all you’re left with is sugar and water, so I tell parents to give their child the peel instead! 

Again with veggies, I tend to suggest for microwaving or steaming as people tend to overcook them when they boil them. They need a crunch as that equals fibre. Root vegetables (potatoes, sweet potatoes, carrots, butternut squash, celeriac, parsnips) – all these lovely fibre rich foods – contain most of the fibre in their skins. I tell parents to roast them, long and slow – they’ll taste better (caramelizes the sugars in the veg/skin) so children will prefer them! 

Be mindful of smoothies and fruit juices. Yes, they can count for 1 of our 5 a day (soon to be 10 a day) but they can have little to no fibre, especially with the models that separate out the pulp. The pulp is fibre!! Try to get them to have whole fruits instead or 1 x 250ml glass of fruit smoothie a day with the pulp. 

5. I have tried all this and it doesn’t work 

Before you dismiss this answer make sure you look over the medical background again (cystic fibrosis, hypothyroid disease, Hirschsprung’s). Ask these all-important questions:

  • When did they have their very first poo? It should be within the first 48 hours. Then double-check it was a good amount – small smears don’t count.
  • Have they had issues with weight gain and prolonged issues with chest problems (in cystic fibrosis, LRTIs tend to happen towards the end of their first year of life).
  • Did they have a Guthrie / heel prick test. Any developmental delay? A large soft spot on their head?

In all of these conditions, the child would have always had an issue with constipation since birth, so don’t miss them. 

Once covered, it’s important to go through what they have tried….. most parents will only have been given a packet of Movicol and told to get on with it. Look at the summary section to see how to structure a constructive management plan.

6. I’m scared they’ll starve so I give them what they want. 

How many of us have been told this with little Jonny sitting there looking larger than life?

In general, throughout the developed world, children are unlikely to starve if their parents are trying to feed them a healthy balanced diet. There are caveats to this:-

  • Autistic children or children with textural issues. 
  • Children with a background of eating disorders (bulimia or anorexia). 

These children will need extra support and input from community and nutritional teams. 

All the other children will always put up a fight (normally a good one!) but then their bodies will give in and want food. This is an important step for parents to understand, especially when the child is too young to go out and get food themselves. Make sure you tell the parents this won’t be a simple task, and the main reason children normally win, is that carers will be busy and won’t have time to tackle this problem. It’s a quick fix to give them something just so that they know they’ve eaten…….then the habit starts. I always tell parents, wait until you have a week off and prepare yourself/ yourselves for a bumpy ride. Have a united front, it’s no good if one parent plays the ‘strict/ bad guy’ whilst the other literally feeds the problem behind their back. Prepare meals and hide away the unhealthy processed snacks (or don’t buy them in the first place) and leave fruit out. Again, get the child involved in cooking, build a healthy connection with food and make it fun. Children will most likely throw tantrums at the start, but remind them that eventually their child’s body will give in and they will come for food, most likely with a grumpy face. 

Just make sure they’re hydrated with clear fluids! And NO milky substitutes. Remind the parents they’re not bad people and this will help fix things in the long run.

7. Movicol doesn’t work and I don’t want it to make their bowels lazy 

This age-old answer…..makes you wonder why we bother using Movicol? More often than not they’ve not prepared it correctly, despite the instructions being on the box. Honestly, the ways parents use Movicol; sprinkle on cereal, mix into snacks or food, add to tea….the list goes on!

Movicol is only effective when it is bound with water. After this, the parent can then mix it with a small amount of any other liquid or flavouring. Make sure they don’t add it to a litre bottle of squash as the child will have to drink the whole lot. Also, this means they don’t need the flavoured versions (which taste vile – remember when they made you try them in medical school!). 

Another myth is that “it’ll make their bowels lazy.” Explain that Movicol is not a stimulant, it is an osmotic diuretic and acts to drive the water you mixed it with into the child’s stool to make them softer and easier to pass. With this in mind, even stimulant laxatives won’t make your bowels lazy. I always say, they can be on it for the rest of their lives, it’ll never make their bowels lazy – that tends to reassure parents.

8. I tried laxatives before and they suddenly had diarrhoea so I stopped using it. 

This answer may again throw you into thinking that the laxative has done a great job in under 72 hours and fixed a months worth of constipation… it sounds too good to be true?? Well, it is. The big problem here is, if clinicians don’t pre-warn the carers what might happen after starting a laxative, it can lead to long term mistrust in both the medication and in our advice.

I always start off by setting the day to start. Aim to start the laxative at the end of the week, a Thursday or Friday, to avoid accidents in the school. They will deter the child from ever trying them again.

Once we know when to take them, always triple check they’re using them correctly… mix with water first, then add to a small volume of any other liquid for taste.

Finally, but most importantly, the change in stool. Referring to the Bristol stool chart (the only card I carry around!), I explain the child will start with Type1-3 stools. Then, they’ll have what looks like diarrhoea, brown watery smelly stools, but, of course, it’s overflow. Take the time to talk about why this happens; the Movicol is slowly moving through the hard stools, like rain trickling down a wall, in their child’s bowel. The Movicol/water mix will initially run over it but over time their stools start to soften. 

The next step, again important due to risk of pain, is the big logs. And big means big! I’ve had parents say they’ve used shears to cut up these stools in the toilet. This is essentially the wall slowly being emptied out. 

Once this is over, they will finally have the soft mushy stools. The laxative story should not end there! It is important to mention this ‘wall of stool’ has caused the bowels to stretch. This will lead to a build-up of stools again as the child won’t know when they need to go. This is reservoir constipation. It can take months to revert back to normal so I always advise to continue on with the laxatives and reduce (but not stop) the maintenance daily dose down if the child is passing clear watery liquid. Usually, treatment should continue for at least three months to treat reservoir constipation (although in some children it can be longer).

9. They don’t like my cooking. They’re vegetarian now, I’m not. 

It doesn’t have to be vegetarian, of course, this is just what an angry mum said to me once about her daughter. Parents will mention the difficulties of preparing food they’re not used to cooking, I always suggest ‘get your child involved‘. This is the perfect time to do something together (bonus points as well in tackling mental health and isolation. It gets the family talking). The child will appreciate their intent and willingness to give their lifestyle a try, which will build confidence in the relationship as well. They can get a cookbook, go online (it’s all free and easily accessible these days) and adapt their cooking style. Again. this will make their child feel more involved and interested in cooking and eating healthy foods. 

10. They don’t like fruit and vegetables. 

I think we’ve all suffered from hating vegetables and fruit at some point in our lives. I remember hating tomatoes and peppers, so I feel for any parent tackling this problem. 

There are several factors to contend with here:

  • Their child not liking the fruit because it’s unknown to them or feels texturally unsatisfactory.
  • Having access to other more ‘enjoyable’ foods such as biscuits, chocolates and crisps around the house which they can graze on and avoid these unwanted bags of goodness. 
  • Watching older siblings and parents, and copying them.

To this, I normally offer a number of solutions but be mindful that parents will have busy lives around their child’s eating habits so it has to be a conscious effort at a convenient time, like over the weekend or annual leave.  

Firstly, hide unhealthy snacks or simply reduce the amount you buy, what they don’t see they don’t know…. out of sight, out of mind technique.

Secondly, I always tell carers that they and older siblings are role models. If you’re not eating it, why should they? There should be a united front by the parents. 

Finally, get cooking and get your child involved. Any child who cooks will appreciate the food they’ve made and the sense of achievement, even if it doesn’t taste nice, they’ll love it. It’s a great time to chat over a bowl of fresh berries…

My own enthusiasm then tends to kick in. I like to say “Get creative in the kitchen!” I’ve mentioned simple things for example: make flapjacks and throw in lots of dried fruits; raisins, dates, apricots, prunes – all-natural sweetness with skinned nuts & oats. Freeze smoothies with the pulp into ice-lollies. Fruit crumbles with honey and oats… With vegetables, always remember to steam or microwave them, they need the crunch. Again if kids don’t like them…. Chop them up/ blend them and throw them into sauces, pies and mixed into other dishes. If it’s the taste they don’t like, again mixed into gravy or a tasty sauce will fix that problem! 

It is important to mention the importance of a healthy balanced diet. Food is your best medicine. This is can be true for managing many conditions; anaemia , skin problems, poor immunity, nail and hair problems..you get my point. A varied diet holds the key to a lot of management plans, and it’s important to mention this even when the child is on supplements. A classic example is the parent says we’ve fixed the iron problem with iron tablets, but they fail to realise, without vitamin C your body can’t absorb the iron through the small intestine. Therefore, they’ll be questioning why their child remains anaemic in months to come. 

11. They’ve gone back into nappies as they’re scared of using the toilet. 

This is an important issue. It’ll mean the child will probably have problems with incontinence which may be affecting their social life such as staying over at a friends houses. Yet another reason why it needs tackling. 

Always start with asking what happened? More often than not it’s a series of bad habits and untimely events that have led to a regression in the family’s good practice. It happens to the best of us. Reassure everyone and give them the positive reinforcement that they’ve identified a problem that needs to be solved. Then offer the advice below. Take your time with these parents, it would have taken a lot for them to come into an acute setting to seek advice, so try to give them some. 

A framework for managing constipation.

This is ultimately an important topic that you have or, no doubt, will see at some point in your paediatric career. Knowing how to manage it is a core skill. 

I always frame my management in 3 steps: 

1. Diet and fluid intake – take the points from the above questions. Ultimately, the parents control the diet and food at home. They, and older siblings, are the child’s role models so what they eat will influence the child’s diet too. Remind them that food is their family’s best medicine so they need to get it right. Cancel out the milky drinks, cook smart & healthy and don’t forget clear fluids.

2. Toileting – our constipation module covers this but key points; get them into a routine (20 to 30mins after dinner – to sit on the toilet). Make the toilet a fun place with all their toys and gadgets and don’t forget to get them to blow the bubbles. Optimise positioning with knees above bums when sitting, using a footstool. 

3. Medication – ensure parents are giving them correctly – mixing with water first then adding to any other liquid for taste. Make sure this isn’t a full bottle, as they’ll have to drink the lot!. Movicol doesn’t make your bowels lazy. If they’re on a disimpaction regime, think about the volume they’ll be drinking each time. It may be better to split it into thrice daily doses instead. Briefly touch on the sequence of stool changes to reduce misconceptions of overflow and diarrhoea. Lastly start Movicol towards the end of the week, Thursday or Friday to avoid accidents at school. 

End with: 

  • Referencing the ERIC constipation website. It’s a great tool for constipation and bedwetting. It talks to the parent and child, so easy to understand and explain.
  • It will take time for things to fall into place. There is no quick fix. There will be tantrums, sleepless nights and days you’ll want to give in. Hang in there and once you’re sorted you’ll wish you’d done it sooner!

Constipation week – Day 4: Evidence on Tough Topics

Cite this article as:
Angela Clarke. Constipation week – Day 4: Evidence on Tough Topics, Don't Forget the Bubbles, 2014. Available at:
https://doi.org/10.31440/DFTB.5638

Bottom line: (pun definitely intended!)

  • A PR examination should only be undertaken by a doctor competent to interpret features of anatomical abnormalities or Hirschsprung’s disease e.g. paediatric surgeons
  • TFTs and coeliac screen should only be ordered by specialists in patients with intractable constipation
  • Abdominal xrays and abdominal ultrasounds are not recommended to aid diagnosis of constipation
  • Dietary interventions alone are not recommended but should be used in conjunction with a laxative
  • According to evidence, PEG 3350 (Movicol) should be the oral laxative of choice
  • Maintenance regimes should be continued for several weeks to months
  • Routine use of enemas is not recommended

See our other Constipation Week posts

Do I order TFTs and coeliac screen?


Thyroid function testing and coeliac screening should only be ordered by a specialist service as part of the investigation of intractable constipation when atypical presentations of these diseases are considered. There are no published studies stating the prevalence of coeliac disease and hypothyroidism in children with idiopathic constipation (Reuchlin-Vroklage et al, 2005).

Should I get an abdominal x-ray to confirm my diagnosis?

Evidence shows that abdominal x-rays play little role in confirming or refuting the diagnosis of constipation as there is poor diagnostic accuracy and reproducibility (Reuchlin-Vroklage et al, 2005). It is important to remember that the average radiation dose of an abdominal x-ray is 0.7mSv, that’s 7 times higher than a chest x-ray. That is relatively high compared to the background yearly exposure of approximately 3mSv (Mettler et al, 2008).

What about an abdominal ultrasound?

Abdominal ultrasounds have shown that children with idiopathic constipation have a larger rectal diameter than those without constipation. However, they don’t give any extra information than what is obtained through thorough history taking and examination and are therefore not routinely recommended.

Which laxative do I choose?

There are a series of case series and randomized control trials that show treatment with PEG 3350 was effective in causing disimpaction of children with constipation.  The studies show that higher doses are more effective than smaller doses and that PEG 3350 is more effective than stool softeners and enemas (Youssef et al, Tolia et al, Guest et al ). There is currently no evidence of the effectiveness of stimulant laxatives in treating disimpaction.

The NICE ‘Constipation in children and young people’ guidelines suggest the following management for children over 1 year of age:

  1. Rule out ‘Red flags’.
  2. Assess for impaction – i.e. overflow soiling and/or faecal mass palpable abdominally. Start maintenance therapy for those not faecally impacted, treat for disimpaction if faecally impacted.
  3. Treat for disimpaction or commence maintenance therapy:
    • 1st line – Macrogol PEG 3350  – escalating dose regime for disimpaction or adjusted according to response in maintenance regime.
    • 2nd line – (2 weeks later) Add a stimulant laxative (e.g. sodium picosulfate,  bisacodyl, senna,)
    • 3rd line – Substitute a stimulant laxative singly or in combination with an osmotic laxative (lactulose) if Macrogol PEG 3350 not tolerated.
    • 4th line – Enema (stimulant laxative: Microlax or Bisacodyl)
    • 5th line – Manual evacuation under anaesthetic.
  4. Continue maintenance regime for several weeks to months.
  5. Medications not to be stopped abruptly but to be weaned over a period of months.

Dosage guides are provided in the guideline – https://guidance.nice.org.uk/CG99.

 

References

Reuchlin-Vroklage LM, et al. Diagnostic value of abdominal radiography in constipated children: a systematic review. Archives of Pediatrics and Adolescent Medicine. 2005;159(7):671-8.

Mettler FA, et al.  Effective Doses in radiology and Diagnostic Nuclear Medicine: A Catalog. Radiology. 2008 Jul ;248(1):254-63.

Youssef NN, et al. Dose response of PEG 3350 for the treatment of childhood fecal impaction. Journal of Pediatrics. 2002;141(3):410-4.

Tolia V, et al. A prospective randomized study with mineral oil and oral lavage solution for treatment of faecal impaction in children.  Alimentary Pharmacology and Therapeutics. 1993;7(5):523-9.

Guest JF, et al. Clinical and economic impact of using macrogol 3350 plus electrolytes in an outpatient setting compared to enemas and suppositories and manual evacuation to treat paediatric faecal impaction based on actual clinical practice in England and Wales. Current Medical Research and Opinion. 2007;23(9):2213-25.

Candy DC, Edwards D, Geraint M. Treatment of faecal impaction with polyethelene glycol plus electrolytes (PGE + E) followed by a double-blind comparison of PEG + E versus lactulose as maintenance therapy. Journal of Pediatric Gastroenterology and Nutrition. 2006;43(1):65-70.

Pashankar DS and Bishop WP. Efficacy and optimal dose of daily polyethylene glycol 3350 for treatment of constipation and encopresis in children. Journal of Pediatrics. 2001;139(3):428-32.

Constipation week – Day 3 – Treatment

Cite this article as:
Tessa Davis. Constipation week – Day 3 – Treatment, Don't Forget the Bubbles, 2014. Available at:
https://doi.org/10.31440/DFTB.5651

Emptying the bowels

There are two essential components – stimulants and softeners. In the past we used enemas and stool softeners. Enemas can be effective, but often you are just unblocking at the bottom end which doesn’t deal with the whole problem.

When discussing the effects of a treatment with families, it is useful to be able to recognise the difference between old poo and new poo. Old poo will be dark, hard, and smelly. New poo will be paler, softer, and less smelly. The aim of treatment is to get rid of all the old poo.

Once the bowel is empty and stays empty, it will return to a normal shape and laxity.

 See our other Constipation Week posts

Stimulants…

Stimulants can be used to help get things moving – these include laxatives, senecot, prune juice, dulcolax tablets (crushed and sprinkled). Senna or bisacodyl directly stimulate the nerve endings in the colon to increase intestinal motility. These are granules which can be eaten plain or mixed with water, milk or food. Cramps and abdominal pain are common. There is some suggestion of it leading to lazy bowel with long-term use.

Often stimulants will be used temporarily to help empty the bowel and will then be weaned.

With Dulcolax, a typical dose would be: 1 per day for a 5 year old; 2 per day for a 10 year old. It is usually given at 3-4pm and works within 3-4 hours. So the child usually opens their bowels that evening or the following morning.

 

Softeners….

Osmolax is one of the mainstays of constipation treatment. It simply adds water to the poo which makes it softer and easier to pass. It does not have an effect elsewhere in the body, simply a local effect on the stool. Therefore, it is safe to keep on taking it indefinitely – and some people do.

The best management is to take the same amount every day. Taking it on alternate days, or even just some days, won’t help – the aim is to soften the poo and so that needs to be done regularly. With children, the usual dose is 1-3 scoops per day (although smaller amounts can be used).

Osmolax is given in scoops, and children seem not to object to the taste too much. When weaning Osmolax, wean down the number of scoops per day. Movicol was the precursor to Osmolax. It does the same job, but it contains electrolytes and so children tend not to like the taste as much. Both of these are types of PEG 3350.

What can we give to babies?

In children under 12 months old, just use lactulose or coloxyl drops. Coloxyl does more than just adding water to the stools – it does get absorbed by the body so it is a drug (unlike Osmolax). Both lactulose and coloxyl are, however, fairly benign. In babies, the cause of constipation can often be due to packing in formula into the bottles (even a 20-30% increase in formula can cause constipation). In infants <12 months old, there is no good evidence that a high fibre diet can treat or prevent constipation. 

How do we know when we succeed?

Usually treatment should continue for at least three months to treat reservoir constipation (although can be longer). Once the child is producing normal diameter stools that are not watery then things are returning to a good place. It’s true that everyone is different. In general, aim for bowels opening every day (at least every two days). Stool should be soft and easy to pass.

There is no rush to wean the meds once this is achieved, and often the child also has to unlearn the fear they have about going to the toilet.