Download Constipation Brochure

Children’s Constipation
Constipation is a frequent problem in children and up to 80% of 80 year olds have signs of chronic
constipation in South Australia. This brochure aims to assist you in managing your child’s constipation.
It is not intended to replace a consultation with your doctor, but to make sure you get the most out of
the consultation. In this brochure a “bowel action” means the same as “doing a poo”. You may have
your own term.
What is constipation?
Once food has passed through our stomach
into our small bowel (intestine), a large amount
of water is added to help digest and absorb the
food. Our large bowel (colon) is designed to
reabsorb water. This makes a formed stool
that we pass. In adults, the large bowel can
absorb up to 10 litres a day. If we are slow to
pass our stool, it becomes progressively harder
as more water is reabsorbed. The harder the
poo, the more difficult and painful it is to pass.
The hard poo can tear the bottom on the way
out and it can bleed. This hurts intensely and
children can get scared of pooing. Then they
hold on. The more they hold on the harder the
poo gets as more water is reabsorbed and a
cycle of constipation begins. This can cycle can
be hard to break and can take a long time. The
frequency of passing poos is variable. A bowel
action as infrequently as 4 times a week can be
normal if there are no other problems.
Colon
Constipation Can Cause Problems
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When a child has stool sitting in end part of the large bowel for longer than normal, the muscles of
the bowel become stretched and weak.
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Dr Kathy Lee, General Paediatrician
Updated Jan 2015
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The bowel regularly sends signals to the brain to tell us if the lower bowel is empty or full. When we
get the signal that it is full, we arrange to go to the toilet at a convenient moment. If we hold on, or
don’t properly empty the bowel, then the brain is constantly getting a signal that the bowel is full.
Over time the brain learns to ignore the signal and not notice it at all. Then we don’t know when to
go until it is too late resulting in accidents.
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If there is a hold up of stool being past, the liquid stool from upstream in the bowel can leak out also
causing soiling

Up to 85% of children with constipation also soil (leak stool out of the bottom) this is due to severe
impaction. It is often confused by parents who think it means their child can’t be constipated.
What causes the hard poo?
There are a few reasons to cause hard poos. This can be:
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Dehydration
o From a fever, not drinking enough water or after gastroenteritis
Diet
o Lack of fibre, high in processed foods, a change of diet (often related to travel) and dairy
causes constipation in a small number of people
Reduced activity
o Such as a long drive in the car and lying in hospital
Holding because
o The toilets at school are dirty, the child would rather play than go when they really need
to, other children look at them under the door when they go at school, they are afraid
of it hurting
Poor bowel habits – see below
Some medication
Fear
o Once the child learns that pooing hurts, they hold out of fear. This is a bad cycle.
Other Emotional Factors
o Anger: Constipation in children that is hard to overcome is occasionally related to
parental anger. The child learns that by holding on to their stool, they upset their
parent. This can give the child a sense of power over the parent. They continue to hold
on to wind the parent up. Breaking the pattern of allowing the child to wind the parent
up is vital.
o Anxiety Issues can also result in constipation. Allowing a child to be relaxed about
passing bowel actions is vital. It is impossible to require a child to pass a bowel action.
Doing so can cause performance anxiety and may make constipation worse.
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Dr Kathy Lee, General Paediatrician
Updated Jan 2015
Some Foods That Are Good For Constipation
Peas (raw or even frozen in a cup as a snack is great) beans, corn and other raw vegetables, lentils,
fresh fruit such as apple with the peel on and apricots, baked beans on grainy bread toasted is an
easy snack, prunes and other dried fruits, and popcorn in children > 4yo (choking risk in younger
children).
Serious Causes Of Constipation Are Unusual
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Infant formula is a recognised cause. You need to find the right formula for your child as no
particular one is right for all.
Some children develop constipation from the introduction of solids. Usually this is related to the
lack of fibre early on.
Surgical causes - If constipation starts from birth, a surgical cause may present, but the vast
majority of children with this problem can’t pass a bowel action at all from birth.
Coeliac disease (gluten Intolerance) can cause constipation or diarrhoea.
Constipation may develop in someone who has hypothyroidism. This is very unusual in young
children. It tends to occur in young women.
Lead poisoning is a rare cause.
Food allergies can cause constipation that is hard to treat. The child starts with diarrhoea that
burns the bottom. They learn to hold and then develop constipation. This is quite uncommon.
Foods that can cause this are dairy, soy, wheat, eggs, nuts and fish. They need to be excluded
from the diet for 3-4 weeks to see a change. When they reintroduced and the constipation will
return quickly. A dietician should be involved when a child has any food excluded long term to
balance their diet.
Good Bowel Habit
A good bowel habit is essential to prevent and treat constipation.
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When the child sits on the toilet, it should not be in an upright position like on a throne. They
should lean forward with arms on the legs as if bearing down in labor. The child’s feet must be able
to rest on a hard surface – the floor or a stool.
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The easiest time to our bowel actions is about 15-20 minutes after having eaten. The body has a
natural reflex that means that when food is put in our stomachs, everything moves along and then
hopefully out. So sitting on the toilet for at least 3 minutes and preferably 5 minutes should ensure
a bowel action most days.
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The best time to pass bowel actions is after breakfast. For busy families, the morning may need to
be rearranged so children get up and eat breakfast, go and get dressed and then sit on the toilet for
5 minutes.
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Dr Kathy Lee, General Paediatrician
Updated Jan 2015
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You cannot make your child poo but you can require them to sit even if they don’t poo. Trying to
make them poo is the fastest way to result in a child holding just to wind you up or in creating
anxieties.
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Privacy in the toilet for a child who is old enough to wipe themselves is important. Constipation can
be monitored by looking for other signs such as soiling, leakage of Parachoc and abdominal pain.
Treating Constipation
Please use this in consultation with your doctor and if needed, paediatrician. It is not intended to
replace seeing your doctor. There are four important phases to treating constipation.
Diagnosis: first is reviewing the causes and making sure there is no serious underlying issue. While this
is very uncommon, it is important.
Clean Out: It is important at the start to clean out ALL retained stool. If this is not achieved, the rest will
fail. By cleanout, what is meant is giving medication so that the stool is watery so no retained slightly
hard stool is present. This is usually done via Movicol or Osmolax in children. See the Women’s and
Children’s Hospital Paediatric Emergency Department brochure.
Maintenance: The aim of this phase is for the stretched muscles to recover and your child to learn to
recognise the sensation of the bowel being empty and full. This will require good bowel habits to be
established. Any fear of holding on should be overcome. Any holding on behaviour means at least
another month of maintenance is required.
This phase should last at least 2-6 months for children with chronic constipation. During this time,
medication is used to keep the stool like toothpaste. It should be easy for your child to go, but not
without some effort. The two routinely used medications are Lactulose and parachoc. They are both
stool softeners, meaning they help water to be kept in the bowel to keep the stool soft. They don’t
stimulate the bowel and so don’t’ do the work of passing the bowel action for the child. For poor diet,
use Fibresure if their diet cannot be changed. This should be done after consultation with a dietician to
see if other options are available. Slowly add to the diet as bloating may occur.
Weaning Phase (Bowel Gym): If you require an unfit person to suddenly lift 100kg they won’t be able.
But if the person goes to the gym and starts with 5kg and then gradually works out, increasing the
weight they are lifting, they will gradually get to lift the 100kg. The same principle applies to the bowel.
Once your child is maintaining toothpaste stool and has a good habit and knows when it is time to go to
the toilet, the medication can gradually be weaned. This will gradually require the bowel muscles to do
more work over time. How quickly you wean depends in part how long the child has been constipated
and in part whether there are any set backs during the weaning process. Remember if any of the risk
factors listed above occur, you may need to increase the medication again briefly.
The aim is to wean by 10% per fortnight. Sometimes you might not reduce at all and if all is going well
wean more quickly. If you suddenly stop, it would be like expecting the unfit person to suddenly lift
100kg.
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Dr Kathy Lee, General Paediatrician
Updated Jan 2015
Abdominal Wall Strength
Another factor in constipation may be low abdominal wall strength. So many people sit and stand with
a slouched posture. As a nation, we are less fit in general and less likely to have strong abdominal wall
muscles. Some basic exercises to strengthen them will help. For example:
Leg Raises: are designed to tone your child's lower abdominal muscles. Have your child lie down on their
back on a bench with their back flat. Then have them extend their legs out until they are parallel with
the ground. Have them tighten her abdominal muscles and lift their legs up off the bench until they are
at a 70 degree angle. Have them hold for several seconds before lowering their legs back down and not
touch the ground. Repeat until fatigued.
However the best option is to get the exercises shown to your child by a physiotherapist.
Other Medication Options
Picolax
Dose
1–2 years ¼ sachet before 8 a.m. then ¼ sachet 6–8 hours later
2–4 years ½ sachet before 8 a.m. then ½ sachet 6–8 hours later
4–9 years 1 sachet before 8 a.m. then ½ sachet 6–8 hours later
9–18 years 1 sachet before 8 a.m. then 1 sachet 6–8 hours later
Acts within 3 hours of first dose. Low residue diet recommended on the day before and copious intake
of water or other clear fluids recommended during treatment Counselling: One sachet should be
reconstituted with 150 mL (approx. half a glass) of cold water; Be warned that heat is generated during
reconstitution and that the solution should be allowed to cool before drinking.
Nulax Fruit Laxative 250g. Contains Senna. Similar taste to dates and figs.
Adult dose 10g: Once daily 3 level 2.5ml medicinal measuring spoons.
Children 5g: half the adult dose. Do not administer to children under the age of 2 years.
If too firm, warm slightly and knead until pliable. Refrigerate after opening.
Laxettes
Laxettes contain Senna; recognised as one of the most popular and reliable natural laxatives. Available
in both tablets and chocolates.
Laxettes Chocolate: are available in packs of 24 and 48 easy to consume squares.
Dosage: Adults and children over 12 years: 1 to 3 squares. Do not exceed 3 squares daily except on
medical advice. Dose to be taken at bedtime.
Important: If symptoms persist, seek medical advice. Drink plenty of water. Increase fibre in diet.
Prolonged use of laxatives is undesirable and may lead to dependence. Do not use when abdominal
pain, nausea or vomiting are present, or if you develop diarrhoea. If you are pregnant or breast feeding,
seek advice of a healthcare professional before taking this product.
Laxettes Tablets: are ideal if you prefer to take tablets rather than liquid or chocolate-based laxatives.
Dosage: Adults and children over 12 years: 1- 3 squares. Do not exceed 3 squares daily except on
medical advice. Dose to be taken at bedtime.
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Dr Kathy Lee, General Paediatrician
Updated Jan 2015
Important: If symptoms persist, seek medical advice. Drink plenty of water. Increase fibre in diet. Do not
use when abdominal pain, nausea or vomiting are present, or if you develop diarrhoea. If you are
pregnant or breast feeding, seek advice of a healthcare professional before taking this product.
Warning: Laxettes should be used as a short term means of re-establishing normal bowel activity while
you are simultaneously correcting dietary problems. They should not be used indefinitely or in excessive
dosages. Prolonged use may lead to dependence
Osmolax: Should not be used as an alternative to Movicol for cleanouts. It is said to draw water in to
the bowel and bulk the stool. It is difficult to wean the dose. However it can be good in the short term
for after Movicol to establish a good bowel habit.
Fybogel (http://www.netdoctor.co.uk/digestive-health/medicines/fybogel.html)
Each dose of Fybogel granules should be stirred into a glass of water (at least 150ml) and taken as soon
as the fizzing dies down. The medicine should preferably be taken after meals. It should not be taken
shortly before going to bed.
Adults and children over 12 years of age should take the contents of one sachet dissolved in a glass of
water morning and evening, after breakfast and evening meals.
Children aged 6 to 12 years should take half to one level 5ml spoonful of granules, depending on size
and age, dissolved in a glass of water after breakfast and evening meals.
Children aged under six years should only be given this medicine on the advice of a doctor.
They should be given half to one level 5ml spoonful of granules, depending on size and age,
dissolved in a glass of water after breakfast and evening meals.
Metamucil Dosage
Adults and children over 12: Take/mix one dose with/in 240 mL of cool liquid at the first sign
of irregularity. Can be taken up to three times daily if needed. Generally produces results in
12 to 72 hours.
Children: 6 to 12 years: Take 1/2 adult dose powder or wafers in/with 240 mL of cool liquid.
Children under 6 years: Consult a doctor.
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Dr Kathy Lee, General Paediatrician
Updated Jan 2015