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   CONSTIPATION

By Mark B. Levin, M.D. and Timothy Patrick-Miller, M.D.
The Pediatric Group, P.A., Princeton


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From time to time, anyone can experience the full feeling that accompanies constipation, defined as firm infrequent bowel movements that are difficult to evacuate. Constipation can include infrequent or painful bowel movements, but neither symptom is necessary for the diagnosis. Bowel movement frequency and patterns vary from person to person. Even three-day intervals between bowel movements can be normal for some children. Indeed, normal newborns, particularly if breast fed, may experience intervals of longer than a week between stools! Constipation is certainly not a pleasant feeling and may be associated with headache and lack of energy. Abdominal pain can supervene if the passage of gas bubbles is obstructed by impacted stool. Sometimes severe, the pain of acute constipation can be mistaken for an acute surgical problem. When constipation is chronic, it can masquerade as colic in an infant and school phobia in a preschooler. If left alone, acute constipation can resolve by itself. Chronic constipation, however, can stretch the bowel, allowing it to retain progressively larger amounts of stool. This vicious cycle can prove difficult to remedy, especially since a stretched intestine becomes less able to signal the need to evacuate.

Prevention via a healthy life style is always preferable to trying to rectify constipation after the fact. Constipation most often occurs in a child whose dietary preference is for constipating foods. Foods with a high starch content, such as tubers (potatoes, sweet potatoes, yams, carrots, acorn squash, butternut squash), rice, breads, cakes, crackers and noodles, are usual culprits. Some children become constipated on cow milk products, either because of a sensitivity to milk or because the metabolism of milk products causes an increased obligatory urinary water loss. Two fruits in particular have a high pectin content - bananas and apples. Pectin is the binding substance that was in the original formulation of Kao-Pectate®. Offering starchy snacks to a child is a sure way to encourage constipation (as well as undesirable weight gain). Fruits (other than bananas and apples), dried fruits, fresh vegetables (other than tubers), nuts for a non-nut-allergic child over five years old (younger children can aspirate them) and meats make fine snacks. Since one of the functions of the gut is to absorb fluid to replace perspiration and urinary losses, insufficient fluid intake, especially in warm weather or in a physically active child, can also contribute to constipation.

Physical activity increases bowel motility and enhances intestinal evacuation. A sedentary life style is a common contributing factor to constipation. Be sure to limit computer and television time. Encourage your child(ren) to spend time playing actively and exercising. In addition to helping out with bowel habits, exercise will benefit your child's heart, lungs, muscles and bones. For children who prefer non-competitive sports, walking, jogging, cycling, jumping rope and swimming are excellent alternatives.

Behavioral factors also play a role in constipation. During toilet training, toddlers may respond to fear of having a bowel movement by withhold their stool. In this instance, a parent's best option is to refrain from pressuring the child about toileting. Preschoolers, and even older children, can become so preoccupied with their play activities that they suppress the urge to defecate and postpone toileting. The stool accumulates and hardens, eventually becoming large or hard enough to cause pain on evacuation. Fear of repeating a noxious experience may cause the child to avoid future bowel movements, leading to an unfortunate vicious cycle of retention. Despite parental efforts to rectify the situation, sometimes a skilled behavioral therapist may needed to help train or retrain a child to successfully evacuate their stool in a painless socially acceptable manner.

For a child who is acutely uncomfortable with constipation, the first step is to encourage a bowel movement in the least uncomfortable way possible. To decrease the pain and the likelihood of fear of future painful movements, have your child sit in a warm bath with the water deep enough to cover the abdomen. Alternatively, a heating pad on the low setting or a hot water bottle on the abdomen will help to ease the discomfort. Since oral intake will stimulate intestinal contractions (a mechanism called the gastro-colic reflex), take advantage of this reflex by encouraging your child to sit on the toilet after the next meal. Offer small volumes of fluids to drink. If acceptable to the child, the laxative effect of prune juice would bestow added benefit. Avoid large fluid volumes, which will stimulate large, uncomfortable contractions. For the younger child, application of some lubricant, such as petroleum jelly, to the anus will make the transition easier. Safe stimulation of intestinal contractions can be accomplished with a glycerin suppository (the pediatric variety for children under eight years of age). This suppository works by its physical presence in the rectum. It does not contain any medication. We do not recommend the old practice of rectal stimulation by a thermometer, even for newborns, because of the risk of injury. If the suppository does not work, contact your pediatrician to discuss the advisability of using a more potent stimulus of bowel movements, such as Ducolax® pills or suppositories, a large dose of mineral oil or a pediatric phospho-soda (Fleets®) enema. Unfortunately, the only way to eliminate firm stool is to evacuate it. There are no preparations that will soften large hard stools.

The contributing factors enumerated in the paragraphs above offer us an opportunity to design a successful treatment strategy. Encouragement of an appropriate life style can go a long way toward regularity. Dietary habits should be amended to include lots of fresh fruits and vegetables. Fruits (other than the aforementioned bananas and apples) are naturally laxative. Non-tuber vegetables contain fiber, which, when taken with adequate amounts of fluid, traps water in the stool, making it softer. Fiber without extra fluid may add to the constipation. Recognizing that it may be difficult to get children to eat the appropriate (or any) vegetables, another source of fiber is Metamucil Wafers®. Two of these cookie-like wafers daily with a glass of water for a pre-adolescent or four daily for a teenager will help. A regularly scheduled toilet time will encourage physiologic and behavioral conditioning, particularly if the time is after a meal to take advantage of the gastro-colic reflex and if it is at a convenient unhurried time (usually after dinner for older children).

If additional help is needed, Children's Senekot®, a mild over-the-counter vegetable laxative, may be used. Always consult your pediatrician for children under five years old or if you are unsure if medication is appropriate. Your pediatrician may recommend chronic Kondremul® therapy or a prescription stool softener, such as lactulose or Miralax®. Kondremul® is a combination of mineral oil and fiber. Lactulose and Miralax® are non-absorbed preparations that draw water into the stool. Should any of these interventions be unsuccessful or the underlying reason for the constipation escapes detection, referral to a pediatric gastroenterologist may be warranted. Always call your pediatrician in the event of persistent abdominal pain.

Newborns are managed differently than older children. The interventions listed above should never be used in a newborn without your doctor's permission. Newborns, who are gassy, will push and grunt as if they need to have a BM with no results. The next stool is often soft. This simply indicates gas, not constipation. As stated above, we do not recommend rectal thermometer insertion as a way to relieve a newborn's gas or constipation. The first day of life deserve a special mention. The rare full-term newborn whose first bowel movement is very delayed may have a congenital bowel problem. If you have a home-born baby, please note and call your doctor at once if your baby's first movement is delayed more than twenty-four hours after birth.

During home management of constipation, be observant of warning signs. Green vomit, persistent pain or blood in the bowel movement warrant a call to your child's doctor. If a constipated child exerts enough force while trying to defecate, the lining of the rectum may actually be forced to protrude from the anus. This rectal prolapse is remedied by simply pushing the lining back in. You should call your pediatrician if this occurs, especially if it occurs more than once. In this instance, your pediatrician may with to do some tests to rule out other causes of this problem.

Last, some constipated children will have fecal soiling as the initial symptom of constipation. When a large quantity of stool is in the intestine, newly forming stool can leak around it and come out in liquid form. This seeming diarrhea is actually a clue that the child is chronically constipated and will require more aggressive management guided by your pediatrician or a pediatric gastroenterologist.

A healthy life style - appropriate diet, activity and rest -- has many benefits, regularity not being the least!


Dr. Mark B. Levin

Dr. Levin has been a member of the staff at The Pediatric Group since 1977. Currently an attending Pediatrician at the Medical Center at Princeton, he has been Chairman, Department of Pediatrics, Medical Center at Princeton, 1984 to 1986, 1989 to 1992, and past President, Medical and Dental Staff, Medical Center at Princeton, 1987 to 1988. Dr. Levin has served on numerous Departmental and hospital committees. He has published original articles both while at Upstate Medical Center in Syracuse and at The Pediatric Group. He has a wife and three children. Dr. Levin enjoys alpine skiing, jogging, hiking and camping, travel, computers and racquetball.

Dr. Patrick-Miller

Dr. Patrick-Miller has been a member of the staff at The Pediatric Group since 1985. Dr. Patrick-Miller has served on several Departmental and hospital committees. He has published original work while at The Pediatric Group. He and his wife enjoy travel. He also likes hiking, biking, gardening and reading.

Pediatric Group 

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