Constipation is a common problem affecting 5 to 30 per cent of children, according to guidelines from the National Institute for Health and Clinical Excellence. Fortunately, in most cases, constipation is transient. Nevertheless, it is highly distressing for the child and for the rest of their family.
Chronic constipation describes persistent constipation and it may have significant medical, psychological, educational and behavioural sequelae.
CAUSES
The causes of constipation are varied and include change in diet, dehydration, stool-holding, certain medications and family history. Often, the cause is not found - so-called idiopathic constipation.
Stool-holding deserves a particular mention. This occurs when a child gets the urge to pass stool, but resists going to the toilet. Eventually, constipation ensues.
Children stool-hold for a number of reasons, including laziness, fear of experiencing pain due to previously large stools or an anal fissure, perhaps only wanting to use toilets at home, or simply embarrassment.
Rarer diseases that may present with constipation include thyroid disease, coeliac disease, an imperforate anus (when the anus hasn't formed properly) in the newborn, or Hirschprung's disease. Constipation is also common in patients who have some neurological and genetic conditions, such as cerebral palsy and spina bifida.
SYMPTOMS
Constipation may present in a number of ways. Irritability, abdominal pain, excessive crying, failure to pass stool regularly, excessive straining, pain on defecation, or passing of hard, pellet-like or large stools are common ones.
Others include offensive flatus, pain on passing stool, abdominal bloating, an anal fissure which may bleed, and a reluctance to eat. Some children soil when they are constipated, in part due to soft stool bypassing very hard stool.
As the constipation continues, the lower bowel may stretch until it ceases to function effectively, and becomes baggy and floppy, rather like an over-stretched spring. The stool may be so solid that it becomes impacted.
TREATMENT
It is important for the constipated child's parents to be alerted so they can seek early medical advice. Transient episodes of constipation or very mild cases may indeed be managed by ensuring children drink plenty of fluids and eat plenty of fibre. Fruit juices such as apple or prune have a laxative effect.
Health visitors or doctors shouldn't suggest dietary advice alone for significant or chronic constipation without other interventions. Some patients may require disimpaction therapies in order to empty any steadfast masses of stool from the bowel.
Oral laxatives, rather than enemas, are recommended in primary care. There may be a temporary increase in abdominal pain or soiling during disimpaction. Treatment after disimpaction, or treatment of chronic constipation in children who aren't impacted, requires ongoing laxative treatment. Doctors may also suggest using glycerine suppositories to allow stool to pass more easily.
DIET AND LIFESTYLE
While dietary and lifestyle changes should not be the only intervention, it should not be ignored. Children should drink plenty of fluids to prevent the stool becoming too hard and to allow the laxatives to work effectively.
Once a child has been weaned, their diet should contain adequate fibre, such as fruits, appropriate cereals and baked beans, but not unprocessed bran, which may increase flatulence.
Children may be helped by a sensible toileting routine, perhaps after eating. It is important not to overstate toileting problems to children, or else they may become frightened and stool-hold.
REFERRALS
Treating constipation may be difficult and take several months to reach resolution. Family support from healthcare workers and schools is crucial. Managing the child's and parents' expectations will help prevent frustration and disappointment.
Where constipation is not resolved in primary care, GPs may refer a child to a paediatrician for further investigations and specialist management. Referral to secondary care is also recommended in children under one year old who don't respond to treatment within one month, children within which a sinister cause may be underlying, and in those with severe symptoms.
In severe cases, children may require an evacuation under anaesthetic. It is not generally recommended to refer children routinely for psychological treatment.
Dr Raj Thakkar BSc(Hons) MBBS MRCGP MRCP (UK) is a full-time GP in Buckinghamshire.
