Children with chronic constipation (constipation that goes on for some time) resist the urge to have a bowel movement. They do this by tightening their anal muscles, squeezing their buttocks together and standing up straight or lying down flat. After a while, the urge to have a bowel movement goes away As they continue to do this, stool builds up in the lower bowel. The stool becomes harder and larger, and passage of stool causes great pain. The pain increases the child's desire not to have bowel movements
If the child doesn't pass the huge stool after some time, the rectal and anal muscles may get tired and partly relax. Soft or liquid stool may leak out around the hard stool that has collected in the lower bowel. It is often foul smelling and may stain the child's clothing. This is called stool soiling. The child cannot prevent it.
This question isn't always easy to answer. Chronic constipation may start as simple constipation caused by not eating enough fiber or drinking enough fluids. One large stool can cause a crack in the anus that makes having a bowel movement painful, so the child resists the urge. Sometimes, a tendency toward constipation runs in families.
An illness that leads to poor food intake, physical inactivity or fever can also result in constipation that lasts after the illness goes away. A few children withhold stools because of emotional problems. In many children, no cause can be found. Whatever the cause of stool withholding, once it begins, the large, hard stools that result make the pattern continue.
The first step in treatment involves removing the stool that has gathered in the lower bowel. This must be done before your child can begin to learn or relearn normal bowel habits. I may do this in the office by disimpacting the stool; this is often very uncomfortable for your child, but must be done. I may suggest an enema, a suppository or high doses of laxatives to remove the stool.
After the stool is removed, it is important to be sure that your child can have bowel movements easily in order to prevent another large collection of stool. During this part of retraining, your child's bowel should be kept empty so it can regain tone and function. The treatment includes changing your child's diet and giving daily laxatives to help soften the stools.
Your child should drink more fluids and eat more fiber. Recommended amounts of fluid each day are 2 cups for a 7-lb child, 3-1/3 cups for a 12-lb child, 5 cups for a 21-lb child, 7 cups for a 35-lb child, and 9 cups for a 60-lb child. Only foods from plants contain fiber. These foods include fruits, vegetables, whole-grain cereals and breads, nuts, seeds and beans.
I can tell you which laxatives to use and how much to give your child. The laxative must be taken every day to get your child's body into rhythm. Laxatives may be given for three months or longer. The laxative I prescribe will be safe for young children, even if it is used for a long time. If your child's stools are too loose, you can reduce the amount of laxative, but keep giving your child a laxative every day. Some laxatives taste better if they are mixed into orange juice, chocolate milk or other drinks.
Some of the bowel medications I often suggest are outlined below. I will go over these during the office visit.
Your child may try to withhold stools at first in spite of the loose bowel movements produced by diet changes and laxatives. He or she may still be afraid of painful bowel movements. The stool withholding will stop after a while. Keep a written record of bowel movements and the use of medicines. This record will help us figure out if the treatment is working.
No. The first goal in treating a child with constipation is regular, painless, easy-to-pass bowel movements. Wait until about a month after starting treatment to begin toilet training if your child is old enough. Encourage the child to sit on the toilet with proper support for the feet. Have your child sit on the toilet at least three times every day for 5 minutes to try to have a bowel movement. After meals is a good time for this. Give rewards and praise for sitting on the toilet and, later, for having bowel movements into the toilet.
After the retraining phase, you can slowly reduce the laxative your child is taking, cutting the dose down a little every week. For many children, constipation returns if the laxative is stopped all at once. If your child's constipation comes back after he or she has stopped taking the laxative, you should begin giving the laxative again at a dose that prevents the constipation problem.
Chronic constipation requires patience and effort on your part. Talk with me regularly so I can follow the treatment's progress and help you make needed changes in the treatment plan.