Constipation concerns

Understanding constipation can be confusing. OHbaby! expert Dr Anne Tait sheds some light on this uncomfortable issue.

It’s not the sexiest topic to discuss, but it is something that most of us do every day – and when it doesn’t happen, it can cause everyone’s life to be miserable. I’m talking about constipation. Unfortunately, there are no ‘constipation awareness days’, Facebook support groups or charities raising awareness for constipation. However, for some families, bowel issues can cause a great deal of confusion and distress; they end up feeling as though their child is the only one with this issue because no one ever really talks about it.

Step by step
It is important to know what is normal in order to identify what is abnormal. This makes it possible to develop a treatment approach to constipation.

Most babies pass that first black tarry motion called meconium within the first 24 hours of life. Usually, after several days, there are transition stools, then milk stools. These are the yellow seedy motions that most babies have. Babies can have greenish, dark yellow or brown motions and these are all still normal. One colour that is not normal is a very pale or white motion. These need to be checked out by a doctor as this can be a sign of a serious problem with a baby’s gallbladder.

There is a difference between breastfed and formula-fed stools. Breastfed babies will have softer, more frequent motions than formula-fed babies, and as babies transition from breastmilk to formula, there will always be a change in bowel motion frequency and consistency –this is normal and is not constipation.

The early days
It is important to determine what defines constipation. Constipation is actually quite uncommon in young babies, and a condition called dyschezia can be mistaken for constipation. Dyschezia is where the baby appears to be in pain or working extremely hard to pass a bowel motion, however, when the motion comes out it is actually soft.

The reason for this difficulty is a lack of coordination between the tummy muscles contracting and the pelvic floor muscles relaxing to enable passage of the motion. These symptoms usually resolve spontaneously, but because of the distress, it is often assumed that the baby is constipated. This can lead to the child being inadvertently prescribed a number of treatments, when in fact the only treatment needed is time. Children under one year old with constipation almost always have hard or pebble-like bowel motions with associated straining.

FIGURING IT OUT
Constipation is uncommon in babies under the age of one, however it becomes more of an issue in toddlers and older children. There are several different criteria for defining constipation from the Rome III group and the North American Society of Pediatric Gastroenterology and Nutrition (NASPGN).

Rome III –two or more of the following:
●  Less than two motions per week
●  More than one episode of soiling per week (after toilet training)
●  Stool holding
●  Painful or hard motions
●  Large diameter motions

NASPGN:
● A delay or difficulty in passing motions for over two weeks moving along

As children get older, their diet changes. During this time they can be perceived to have constipation when they are actually very normal. Children aged between one and four in American, Italian and Australian studies, generally pass one or two motions each day.

In children, there are three stages where constipation can become an issue: the transition from breast to formula or solid feeding, in toddlers starting toilet training, or in school-aged children who don’t want to use the school toilets. Often there is a hard or painful motion initially, which causes the child to hold on so they avoid experiencing any more pain. Like a breakdown in the Auckland motorway system, this can quickly result in a serious backlog of traffic in the large bowel. The large bowel is a thin muscular tube which has the ability to expand, meaning that when it is full of bowel motions from the child holding on, it doesn’t contract as well to empty. Meanwhile, water and salts from the motion continue to be absorbed, so the motion becomes harder and more difficult to pass. This results in more stool-holding behaviour, which causes the vicious cycle to continue.

Signs and symptoms
When there is poo in the rectum, the rectum secretes mucus to enable the poo to pass. At times it can look soft, but be very large, which can fool parents into thinking that their child isn’t constipated. At other times there can be loose motions because of this mucus, which causes soiling. In the old days, children were assumed to be lazy when they soiled, but this is not the case. In these cases the child simply isn’t aware that their rectum is full as it has been chronically distended for months, so the motions slip out unexpectedly. In the majority of the cases I have seen, soiling indicates constipation.

Constipation can present with urinary symptoms, including urinary frequency and infections. This is because a full rectum presses on the bladder, resulting in the bladder not being able to fill or empty as it should. Another presentation of constipation can be recurrent abdominal pain. A full family history and examination is necessary to exclude other rare causes of constipation, such as hypothyroidism, anatomical causes or coeliac disease.

When considering constipation, I always go through the Bristol Stool Chart (do a Google image search, if you dare!) to determine what type of motion is being passed, and how often. I also consider if there is straining, blood on toilet paper, or if there are very large, intermittent motions and associated bladder dysfunction. A good dietary history is also really important to take into account.

There is help
We all have a different bowel transit time, which is the time taken for food to go in the mouth and then come out the other end. For those with a slow transit time, attention to diet is incredibly important. My recommendation is for a whole food diet.

The lack of fibre in processed foods negatively impacts on bowel transit time. When referring to processed food, I mean anything (yes, anything) that is in a jar, a packet or a can. Whole food is exactly that: the whole food which needs to be cooked from scratch. Also, aim for at least five servings of fruit and vegetables a day.

Treatment of constipation involves dietary manipulation first, then sitting on the toilet for 15-20 minutes after a meal to take advantage of the gastro-colic reflex.

Asking the child to put their feet up on a foot stool while on the toilet can help the pelvic muscles to open up more, allowing the motions to pass out easily.

For most children who come to see me in clinic, laxatives are required. The types of laxatives are limited for children because of the taste and palatability, and they all have their pros and cons.

My personal preference isn’t for any particular laxative over the other, but rather one that the child is going to take willingly and regularly.

Most children require treatment for as long as they have had symptoms. The most common causes of treatment failure are coming off the medication too soon, not improving the diet and not having good toilet habits.

It’s important to make going to the toilet a relaxed experience. If a child associates passing a bowel motion with pain, then they will hold on until they are at the point of no return. I recommend waiting until the child is passing soft, pain-free motions for several weeks before going back to sitting on the toilet or potty. This is because the pain association with toilet training will be counterproductive.

For further advice, a good resource is the Starship and NZ Paediatric Society website kidshealth.org.nz. 

Dr Anne Tait is a general paediatrician employed at Starship Children’s Hospital, who also works in private practice at Auckland Medical Specialists. She has an interest in all areas of children’s health and well-being.