Download Childhood Constipation - Interior Health Authority

Childhood
Constipation
Toddler/Children
Public Health Nursing and
Community Nutrition Services
Interior Health Authority
February 2013
Feedback welcome to
[email protected]
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Developed by:
Sandy Feil, R.N. BScN. Public Health Nurse, Interior Health
Cathy Richards, Community Nutritionist, Interior Health
Reviewed by:
Dr. Shari Claremont, Family Physician
Dr. Mark Duncan, Pediatrician
Dr. Thomas Kinahan, Urologist
Dr. Kim Burrows, Pediatrician
Approved by:
Nadine Johnson, Practice Lead Promotion and Prevention,
Community Integrated Health Services, Interior Health
Dr. Gerarda Cronin, Medical Director,
Perinatal and Child Health Network, Interior Health
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Table of Contents
Introduction ......................................... 4
What is constipation .............................. 4
Symptoms of constipation ..................... 4
Encopresis ............................................ 5
What causes constipation ..................... 6
The digestive system ............................ 6
Management of Constipation ............ 7
Routine ................................................. 7
Listening.Signs to Watch For ................ 8
Daily bowel diary ................................... 9
Nutrition .............................................. 10
Medication .......................................... 11
Activity ................................................ 14
School ................................................. 14
8 Tips .................................................. 16
Pulling it all together ........................... 17
Glossary of Terms ............................ 17
Resources for parents ...................... 18
Informational Websites ....................... 18
Books .................................................. 18
References ........................................ 19
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INTRODUCTION
The purpose of this booklet is to help you better understand
and manage your child’s constipation. It is meant to help you
when you talk with a health care professional (doctor, nurse,
dietitian, nurse practitioner).
A daily routine including good nutrition, medication, activity
and positive parenting all play an important role in treating
childhood constipation.
What is Constipation?
Constipation in children is defined as “a delay or difficulty in
defecation, present for two or more weeks, and sufficient to
cause significant distress to the patient”. *
Symptoms of Constipation
Many symptoms can occur with childhood constipation:
 dry, hard painful bowel movements
 very large bowel movements
 fear of passing a bowel movement or even sitting on
the toilet
 blood mixed in the bowel movement, caused by small
rips or tears at the anal opening (called anal fissures).
These are very painful and often take a long time to
heal
 poor appetite
 abdominal pain, cramps and bloating
 being bad tempered
 feeling sick and/or throwing up
 frequent peeing and bladder infections
 tensing the stomach or bottom to try to prevent having
a bowel movement
 encopresis
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Encopresis (Soiling)
Encopresis, or “soiling” is a common result of long term constipation. As the large intestine becomes more and more
stretched, liquid stool from the small intestine leaks around
the hard formed stool in the colon. This will appear as
“accidents” in their underwear.
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This is often upsetting for both parents and children.
Children have no control over these “accidents.”
Don’t be surprised if your child denies having soiled
themselves as (s)he often will not have noticed there is
stool in their underpants.
What Causes Childhood Constipation?
97% of the time, the cause of constipation is not known.
A child with constipation should be checked out by a
doctor or nurse practitioner (NP) to rule out any medical
causes. Most times, there is no medical cause.
There are many triggers for constipation:
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having one hard or painful bowel movement (BM), and
then being afraid of the next urge to have a BM
a negative toilet training experience
feeling stressed
a change in regular routine
not drinking enough fluids
some medications
Constipation can sometimes go on for awhile
before it is recognized.
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The Digestive System
It helps when parents and school aged children understand how the body breaks down food (the digestive
system) and what happens in the body when constipation happens.
Use the picture below to help you understand the
digestive system. You may also want to review it with
your health care professional.
Small Intestine
(small bowel)
About 20 feet long.
It absorbs nutrients
from food into the
bloodstream to give
the body energy
It sends digested
food to the large
intestine
Esophagus (throat)
Food moves from the
mouth down the
esophagus into the
stomach
Stomach
Mixes food with
digestive juices
Large
Intestine (large
bowel-colon)
is about 5 feet
long
-absorbs water
from the digested
food and forms the
stool
Rectum
Muscular tube that
holds stool until
the body is ready
to have a bowel
movement
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MANAGEMENT OF CONSTIPATION
Routine
The “urge” or “feeling” to have a bowel movement usually
occurs 1-2 times a day as stool moves into the empty rectum
and stretches it.
Usually the body sends this message to the brain about 1520 minutes after eating. Having your child practice sitting on
the toilet after eating breakfast and supper will help to train
the bowel to respond to this call.
If you do not respond to the message, the urge will pass, the
stool will sit in the bowel and get larger, harder, and drier.
Many children with constipation may be fearful and hold back
on the urge to have a bowel movement (BM).
It is important to teach your child to “listen to your body” or
“listen to your bottom” and go to the toilet when they get the
message.
Sometimes a warm bath, active playtime or tummy massage
will help move the bowels.
Children who are toilet trained should practice sitting on the
toilet for 5-10 minutes every day after each mealtime. This
is very important to their success.
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Listening/Watching for signs
When children try to stop the urge to have a bowel
movement they may:
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suddenly stop whatever activity they are doing
hide or leave the room
stiffen up, extend their bodies upright, stand on their tip
toes and tighten the muscles in their bottom
suddenly squat or sit down
make a face or change the tone of their voice
begin to sweat or become pale
not be able to pay attention to you
Ask your child “what message is your body/bottom giving
you?” and take them to the bathroom.
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DAILY BOWEL DIARY
It helps to keep a record of your child’s medication and bowel
movements.
Date
Medication
Sat on
Toilet
BM size &
Consistency
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Soiling
accidents
Nutrition
It is important that your child eat a healthy diet.
Following Canada’s Food Guide, including fruits and
vegetables and some whole grains, is a good way to ensure
your child is eating well.
www.healthcanada.gc.ca/foodguide
Tips:


routine meal times help with routine
toileting; don’t skip meals or snacks
offer water often. Avoid too much milk, juice or pop
Extra fiber will help your child’s bowel habits, but not until
the constipation is resolved.
Canada’s Food Guide
If you need help with your child's diet, ask your doctor or
Nurse Practitioner for a referral to a dietitian, if possible one
who specializes in pediatric nutrition.
For free nutrition information you can
call 8-1-1 and ask to speak to the
“Pediatric Dietitian” at Healthlink BC.
Here are some helpful websites:
www.hc.sc.gc.ca/fn-an/food-guide-ailment/index-eng.php
www.healthlinkbc.ca/dietitian/
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Medications
Medications are often very helpful to get into a comfortable
routine with toileting. The goal is a daily bowel movement
with no soiling.
Medications should only be prescribed by a doctor or Nurse
Practitioner.
Do not use food or fibre to treat constipation unless advised
by your doctor.
Often parents worry that their child’s body will get used to the
medications (laxatives) and not have a natural urge to go or
that the medications may drain the body of other important
nutrients. When used correctly, this will not happen.
Give medication at the same time each day.
Often the medication can be mixed in a drink such as juice.
You need to know the safe range or dosage for your child’s
medication(s) so that you can adjust them as needed. Don’t
wait until the next appointment to find a dose that works.
The first step in treating
constipation is to empty the
large intestine (bowel).
Get to “one a day!”
One comfortable
bowel movement
every day.
These methods are commonly
used to do this:
 enemas push fluid into the rectum, causing the urge to
have a bowel movement
 suppositories irritate the bowel, causing it to push out a
bowel movement
 laxatives flush out the lower bowel
 disimpaction—sometimes a nurse or doctor need to
manually help very large and hard stools to come out
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Keeping Bowel Movements Regular
Daily laxatives help constipated children have soft, pain free
bowel movements.
Medication for Constipation
Your doctor may prescribe one or more of these treatments
to produce soft, painless bowel movements. To keep bowel
movements regular, your child may need to take the
medication for a period of time.
There are three main types of medications (laxatives):
 Water retaining
 Stimulant
 Lubricant
Water Retaining Laxatives
These are the most commonly used laxatives for childhood
constipation. They help keep water in the stool so it is softer
and easier to pass. Some of these include:
 Polyethylene glycol (PEG) 3350™ (Lax-A-Day)
 Lactulose™
 Milk of Magnesia™
Stimulant Laxatives
These medications speed up the passage of stool by irritating
the lining of the intestines:
 Senokot™
 Dulcolax™
 Fletcher’s Castoria
 Ex-Lax™
Lubricant Laxatives
This medication helps bowel movements by coating the stool
with a water proof film, keeping it soft and easy to pass.
Lubricant laxatives may cause some staining in your child’s
underwear:
 Mineral Oil (Lansoyl™)
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Prebiotics such as inulin (Benefibre™, Metamucil™ and
Simply Clear™) help healthy bacteria to grow in the
gastrointestinal tract which adds soft bulk to stools.
Probiotics are the actual healthy bacteria cultures. Both are
still under study for use in children and should not be used if
your child has an immune deficiency disorder. Consult with a
doctor before using prebiotics or probiotics.
Bulk Forming Agents such as Psyllium fibre
Metamucil™, Citrucel™, Fibercon™, and Fiberall™ are
fibre-based medications that dissolve or swell in the
intestines, lubricate and soften the stool, and make the
passage of bowel movements easier and more frequent.
Stool Softners Are laxatives that prevent hardening of the
stool by adding moisture.
 Colace™
You need to understand that treating constipation is often a
long journey. The symptoms may take many months to
resolve. The medication routine you have set up for your
child may suddenly stop working and need to be reassessed.
It has been described as a game of snakes and ladders!
Eventually you will win the game but not without many ups
and downs.
Although many healthy children do not have a BM
everyday, the goals for a constipated child are to use
medication to help him or her to have a regular daily
bowel movement without discomfort, and to stop soiling
in his or her underpants.
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Activity
If a child is constipated he or she may have little energy and
may not want to play or be active.
However, daily activity is important to
help move food through the bowel.
Using back, stomach and leg muscles
helps intestinal health.
Keep in mind that being active helps
the bowels move, so be prepared! It is
a good idea to take a bag of moist
wipes, clean underwear and any other
items you may need when you are
away from the house.
School
As with any health condition, it is important that your child’s
teacher be informed about your child’s
constipation.
Your child may need a “safety net”. This may mean using a
“secret code” which tells the teacher that he or she needs to
go to the bathroom. Your child should NEVER have to wait.
Some children need privacy, such as a single stall bathroom
where nobody else will come in. Your child will need to know
where all the bathrooms are in the school, so that he or she
will not panic trying to find one.
Clothing should be easy to remove. Depending on the
severity of your child’s constipation/or soiling, it may be
necessary to keep a change of clothes at the school.
Children with encopresis or soiling are likely to be teased or
bullied due to odor. Talk to your child’s teacher, family
members and siblings about this, to prevent your child from
being bullied.
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8 Tips for Parenting Your Child with Constipation
Constipation is a digestive problem, NOT an emotional
problem. Children do not withhold bowel movements or soil
themselves to cause trouble or rebel.
However, many children with constipation show behavior that
can be very frustrating to deal with. You are not alone.
Here are a few suggestions:
1. Look after your child’s self esteem.
Praise him or her for accomplishments no matter how
small; for example, taking medication when asked or
sitting on the toilet after meals.
2. Set limits and be consistent.
Set rules that will help your child understand what they
need to do to overcome their constipation. This includes
taking medication, eating healthy, drinking enough fluid,
listening to the message their body is sending, and taking
time to sit on the toilet every day.
Sometimes a simple reward chart will help. Keep the
rewards simple. A trip to the park, a bike ride together, a
small toy, etc.
3. Make time for toileting.
Make sure your daily routine has time for your child to sit
on the toilet without feeling rushed. This may mean both
of you getting up 10 minutes earlier in the morning, or
planning dinner time and evening activities with time in
between to sit on the toilet. Your child should only sit on
the toilet for 5-10 minutes. Depending on your child’s age,
it may be unrealistic to expect him/her to sit alone. Sit with
your child in the bathroom, have a chat or read a book.
Help them feel clean after toileting. Keep some moist
wipes handy when away from home.
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4. Be a good role model.
Let your child know when your body is sending you a
message to have a bowel movement. Let them know you
are going to the bathroom right away.
5. Be flexible and willing to adjust your parenting style.
Although keeping a routine is important, a little flexibility
goes a long way.
6. Make communication a priority.
If your child is old enough, talk with them regularly about
how he/she is progressing and how medications, healthy
eating, and active play are helping (in simple terms). The
more your child understands, the easier it will be to have
their co-operation.
Allow your child to express feelings; there may be days
when he/she feels down or frustrated
7. Show that your love is unconditional.
Never punish or tease your child for soiling or for not
having a bowel movement. Try not to be frustrated when
their toileting needs interrupt your plans for the day.
Having a bowel movement is important for their comfort
and health. It is not important for your love or pride. Your
child needs to know you love and support him/her
regardless of their success. This same message needs to
come from all family members and care providers.
8. Be aware of your own needs and limits.
Dealing with your child's constipation can be both
frustrating and embarrassing. Everyone has bowel
movements and everyone has struggles from time to time.
Talk openly with family, friends and health care
professionals. Share what you and your child are going
through. It is important to have their support and
understanding.
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Pulling it all together
Supporting your child to have regular bowel movements
requires:
 daily routine
 healthy nutrition
 medications
 daily activity
 supportive parenting
Be patient—with time, it will be resolved.
GLOSSARY OF TERMS

Abdomen: Tummy

Anus: Outer opening of the rectum (bottom)
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Bowel Movement (BM): Passage of stool (poop) from the
rectum (bottom)
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Large Intestine: See page 6
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Laxative: Medications taken to encourage bowel
movements and relieve constipation
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Pediatric: Concerning the treatment of children
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Rectum: See page 6
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Small Intestine: See page 6

Stomach: See page 6
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RESOURCES FOR PARENTS
Informational Websites
KidsHealth—many health related topics including
constipation, toilet training, parenting, etc.
http://www.kidshealth.org
University of Virginia, School of Medicine
www.medicine.virginia.edu/clinical/departments/pediatrics/
clinical-services/tutorials/constipation
Interior Health Authority
www.interiorhealth.ca
Other resources
Your local Health Unit– Public Health Nurse
Books
How To Get Your Kid To Eat...But Not Too Much by Ellyn
Satter, 1987, Bull Publishing Company
ISBN 0-915950-83-9
Child of Mine : Feeding with Love and Good Sense Ellyn
Satter, 2000, Bull Publishing Company,
ISBN 0-923521-51-8
BC Healthlink
Dial 8 -1-1
Talk to a Nurse 24 hours/day, 7 days/week
Pharmacist available between 5 p.m. - 9 a.m. daily
Dietitian between 9 a.m. - 5 p.m. - Monday to Friday
www.healthlinkbc.ca
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REFERENCES

*Constipation in Infants and Children: Evaluation and
Treatment, A Medical Position Statement of the North
Amer. Society for Pediatric Gastroenterology & Nutrition.
JPedGastrNut, 29(5):612-626, 1999

Chronic Constipation and Encopresis in Children available
at http://www.hsc.virginia.edu/cmc/tutorials/constipation

http://www.kidshealth.org

http://www.cfp.ca
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Comments /Feedback
Please send any comments or feedback regarding this
information booklet to :
Interior Health Authority
[email protected]
Reorder # 82472
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