My 19-month-old daughter, Caitlin, suffers from constipation. I have been to a number of doctors, and paediatricians, and still have a problem with her constipation. I have tried various medicines and suppositories (she screams at the sight of them!). Caitlin attends a nursery school and eats her meals there, which I feel are balanced and healthy. I have also tried prune juice, purity and fruit. What more can I can do to help her? Dianne Swart
This is a very common problem and is very distressing for the child as well as her parents. Constipation refers to the passing of very hard and very infrequent stools. Typically children with constipation will pass a stool once every 4 or 5 days and will scream with pain when they pass. They sometimes will only pass if given a laxative or suppository and this can go on for months or year.
The most common cause of constipation is “functional”. This means that there is nothing seriously wrong with the gut but something in the diet is causing constipation. This could be eating too much of a certain food like bread or cow’s milk, or a lack of something like fibre from fruit and vegetables, or too little liquid.
Watch the diet
A good starting point is to increase the amount of fruit, vegetables and water or juice and decrease the amount of milk. 19-months-old is a typical age for children to be very fussy eaters and feeding them fruit and vegetables can take some ingenious thinking.
Passing hard stool can cause a small tear in the anus, which is called an anal fissure, which may bleed and is painful. This then heals, but every time the child strains to pass stool the pain returns and the tear can open again. This can go on repeatedly and eventually the child will resist passing stool until she is completely blocked with stool. It is important for a doctor to examine the anus and if a tear is present then this needs to be treated.
The foundation of treatment is to soften the stool. The easiest way to do this is by dietary means with fruit, but a liquid preparation of Lactulose (Duphalac, Senokot syrup, Lacson, Laxette) works really well as long as the correct dose is given.
The recommendation is to start at 1ml per kilogram per day (a 12kg child takes 12ml per day) and to increase to as much as 3ml per kilogram per day (a 12kg child takes 36ml per day). If you have to use a higher dose to achieve stooling, then consult your doctor.
It is very important that the stool is kept soft for weeks to ensure that the tear heals properly and that the bowel is completely cleaned out. It is completely safe to use Lactulose for weeks at time. Occasionally the tears are so bad and old and hard that a small surgical operation is needed to correct the problem.
If there is no tear and the problem does not correct with aggressive use of Lactulose and dietary correction, then we need to find out what the problem is. There are conditions that will cause constipation and these can be detected by careful examination and some minor investigations.
Problems can occur with the nerve supply to sections of the colon and rectum and these can also cause constipation, such as Hirschsprung’s disease. Here the diagnosis is made by performing a barium enema or a biopsy of the rectum.
Rather than going through the list of rare causes, let’s just say that if the problem is not solved by following the advice above then you should seek help. If your current medical providers have not managed to sort out the problem then you should try to get to see either a paediatric gastroenterologist or a paediatric surgeon.
Constipation is a common and frustrating problem in children. Children become constipated for a number of reasons, including too little fibre in the diet, not drinking enough water, or purposely trying to hold in their stool if they’ve had a painful experience while having a bowel movement. Possible solutions to constipation include:
Drinking plain water is the best choice of fluid. A cup of water should always be available to sip on. Don’t wait for your child to ask for something to drink because thirst is the first sign of dehydration, so offer water at all times. You can judge if your child is getting enough water by the colour of her urine: the darker the urine, the more likely she is not drinking enough water.
Fibre in the diet is obtained from all wholegrain unrefined starches, legumes, fruits and vegetables. At the age of 19 months, your child needs:
- 3 servings of wholegrain unrefined starch, where a serving is equivalent to half a slice of bread, or half a cup of cereal or cooked starch. High fibre starches include: seeded breads, brown rice, barley, quinoa, popcorn, oats, oat bran or bran flakes.
- Try to avoid refined starches such as white bread, refined white porridges or sugared cereals, biscuits, chips, pizza, sweets or chocolates.
- 4-5 servings of fruit and vegetables, where a serving of fruit is 1 small fruit; 2-4 tablespoons or 90g; a serving of vegetables is 2-3 tablespoons. Always serve fruit and vegetables with the skin on where possible, as the skin is particularly high in fibre. Eating fresh fruit is a better option compared to drinking fruit juice since there is more fibre in fresh fruit, and often fruit juice replaces water in the diet which is not ideal.
Keeping a food diary may useful as this may help identify any refined carbohydrates in her diet, as well as to determine whether or not she is eating enough wholegrain unrefined starch, fruit and vegetables to obtain enough fibre in her diet.
Most toddlers are naturally physically active. Exercise is important for regular bowel movement. Try to ensure that Caitlin is active throughout the day, running, jumping and playing on the playground.
It is important to develop a regular toilet habit. Encourage your child to sit on the toilet for 5 to 10 minutes after a meal, even if she doesn’t pass a stool. This designated potty time allows a calm routine where your child can relax and let nature take its course.
Positive reinforcement is important for regular bowel movements. Remove any negative thoughts about being constipated. The use of simple rewards such as a daily star or sticker on a calendar when she has a bowel movement may be helpful.
A daily dose of a probiotic may assist with alleviating constipation. Probiotics improve the good natural bacteria (flora) in the gut, which assists with colon movements. An imbalance in the colon flora has been suggested to play a role in constipation.
Therefore, up to 4 capsules a day (taken all together) should be given to your child until a proper bowel movement takes place. This could take as long as a week. Ensure that the probiotic contains a Bifidoflora, which is necessary in the large bowel.
Prebiotics are also an important constituent in the diet, assisting with the growth of flora in the bowel. Prebiotics can be found in food items such as oat bran, ground flaxseed, fleshy parts of fruits and vegetables, or even soluble fibre supplements added to food. Once a proper bowel movement is achieved then you can gradually reduce the dose of the probiotic each day until 1 capsule per day is given.
Try to reduce the frequent use of laxatives as this may cause a “lazy” gut and worsen the constipation. First try simple behaviour modification and use a laxative only when indicated by a medical practitioner.