CONSTIPATION IN KIDS – SIMPLE AND EFFECTIVE WAYS TO AVOID AND MANAGE IT

Constipation is a common health problem that your little ones face during their developmental phase. It is as common as 30% in paediatric age group. That means, almost every third child is constipated at some point of time. It may not be a major health issue, but it is definitely distressing both for the child and the parent.

What is constipation?

There is a common belief that not passing motion daily is constipation. But that is not true always. In case of new-borns and infants, passing 1 or 2 potty per week should be absolutely fine; provided the poop is soft in consistency. To call a child as constipated there should be a

Delay (less than 3 times a week) and

Difficulty in Defecation (straining and passing hard pellet like poop) causing

Distress to the baby (pain and bleeding)

Do you need to be worried if your little one is constipated?

90 – 95% of constipated children do not have any underlying medical conditions. They are just habitually constipated. This is called functional constipation. Only in a small percentage of kids (5%) there is an underlying medical condition like thyroid disease or bowel muscle or nerve problems or anal hole positional problems. The following symptoms should alert you to consult your paediatrician immediately

Onset of constipation in the newborn period or early infancy.
Constipation lasting for more than 1 month.
Associated poor weight gain / bloating / vomiting.
Disturbances in bladder and bowel control (incontinence)

What makes your little one get constipated?

The following are some common scenarios we see in paediatric office practice:

“She was absolutely fine till 6 months doctor, once I started complementary feeds she started passing hard poop”

“Everything was fine till last month, I put him in day care and now he is always blocked doctor“

“Ever since I started to potty train him, he is constipated. He stands cross legged, squirms and tries so hard to push it, still he couldn’t do it“

What is common in all the above settings? It is A CHANGE. Such as

A change in the diet (commonly during introduction of complementary foods /during travel) or
A change of place (starting school / visit to a guests house / during vacation) or
A change in routine (during travel / potty training period / new care giver / sickness)

During such a change, the child withholds doing potty voluntarily. This is either because the new food has changed the consistency of the poop and he is finding it a little hard to push, or he doesn’t want to do it in a new place, or he is angry that he is forced to do potty only in the potty chair, or he doesn’t want to leave his play halfway and go do potty.

Such withholding makes the poop go dry and hard in the rectum (the last part of the large bowel where poop gets collected before being passed ). When this hard poop is being pushed out, it causes pain and sometimes bleeding. Such a traumatic pooping, makes the child withhold further without completely emptying. This leads to a vicious cycle of dry , hard poop and a distended rectum.

This chronically distended rectum, looses its ability to sense fullness as well as its ability to contract (like an over stretched rubber band ). This makes it difficult for the child to even pass a soft poop later on. The constipation now continues for a longer time. Even after evacuating the impacted poop, the child gets blocked repeatedly making the treatment difficult.

Sometimes, the newly formed soft poop could seep around a hard impacted poop and soil the child’s diaper. This is not diarrhoea but overflow incontinence due to severe constipation.

Overflow incontinence/ fecal soiling

In a child who is constipated, if you find him / her standing cross legged , squirming don’t think it as an attempt to do potty. It is in fact a withholding posture. The child is trying hard not to do potty because he fears the pain.

How to manage your constipated little one?

The management highly depends on whether the problem is mild / short term or severe / long term.

Mild / short term constipation:

If it is a new onset problem that has happened only a few times, some dietary modification and behavioural therapy should be enough.

DIETARY ADVICE FOR A CONSTIPATED CHILD –

Fluids – water should be consumed in an adequate amount for proper hydration and formation of soft poop. Remember, it’s only adequate water. Do not force your little one to drink more and more water just because he is constipated. That being said, just consuming lot of water without adequate fibre in diet is not going to help in constipation at all.
Fibre rich diet – including adequate amount of fibre is very important to produce soft poop. For that include lots of
Lentils and legumes – chickpeas, red beans, black eyed beans, green gram, kidney beans, green peas etc.
Fruits – sapota, guava, avocado, apples and pears with skin, kiwi, oranges, papaya, berries etc. As far as banana is concerned it is an average source of fibre.
Vegetables – broccoli, cabbage, carrot, beans, beet root, cauliflower, green leafy vegetables etc.
Cereals and millets – oats, Quinoa, whole wheat, barley, amaranth, corn etc.
Nuts and seeds – chia seeds is rich in fibre. Almost all nuts and seeds contain good amount of fibre .
Restrict milk intake to only the required amount. Too much milk can be constipating.
Avoid snacks made of refined flour like biscuits , pizzas, burgers, cakes and pastries.

BEHAVIOURAL THERAPY –

The mainstay of treatment in a constipated child is preventing or breaking the voluntary withholding cycle. This can be achieved only by behavioural modifications.

Teach your little ones not to control the potty. They should do it whenever they feel like doing it.
Whenever they do potty they should empty completely.
Use a squatting rather than sitting position for potty (that is when the rectum is in line with the anal hole). For this, use an Indian style commode or use a stool in a western style commode.

Make use of gastro colic reflex – it is easiest to do potty immediately after a meal when the stomach is full.
Make some time after breakfast for your school going kids to empty their bowel. So that they don’t have to control it on the way to school or at school.
Avoid early potty training – preferably not before 2 years of age. If they are taught to control potty too early, they won’t understand when to control it and when not to control it. This may lead to excessive withholding.

For more details on dos and don’ts during potty training refer to my blog on that topic. The link is below

Read: How to successfully toilet train your child – Dos and Don’ts during potty training

PHYSICAL ACTIVITIES –

Abdominal massages ( circular massages around the belly button in clockwise direction ) helps in better bowel movements particularly in infants.
Physical activities like sit ups and pelvic floor exercises also help to an extent.

ROLE OF ANAL STIMULATION –

It is a traditional practice in many Indian households to stimulate the anal hole of the babies with a leaf stalk ( commonly beetle leaf or tamarind leaf ) or soap stick. This should highly be discouraged due to risk of local injury and inflammation. Moreover, this is only a temporary relief and does not address the underlying problem.

Severe/ long term constipation :

If the constipation problem is something that is continuing for more than 1 month, in addition to dietary and behavioural modifications, the child needs medical treatment with stool softeners. I know some of you had already done this, as per your doctor’s advice. But after stopping the medications, your child again got constipated. This cycle repeated over and over again. You were even concerned about the side effects of those medicines and stopped using them overall. So now comes the big question – how to provide an effective long term relief to your child?

How long should your little one take stool softeners? Are they safe ?

As I already mentioned, a chronically distended rectum is like an over stretched rubber band that has lost its elasticity. It can regain its original shape and function only if it is allowed rest longer. So, it is very important to continue the treatment with stool softeners for longer time (anywhere between 3 months to 1 year ) .

These stool softeners usually have negligible absorption into our body. Literally, there are no side effects. So long term treatment should not concern you much.

Untreated constipation leads to complications like anal fissures, rectal prolapse and fecal incontinence. Encourage your little ones to have