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.
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.
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.
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.
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.