What is Constipation in Children?

Constipation is difficult to define and its meaning differs from person to person. For some, it may be a decrease in stool frequency, for some it may be very hard and difficult defecation, and for others it may be pain while defecating. It can be defined simply as difficulty or delay in defecation.

Internationally accepted definitions are as follows: Constipation or constipation is hard stools regardless of the frequency of defecation in children.

Another definition is defecation less than 3 times a week, hard mass, painful defecation and optional stool retention. The consistency of the stool and the percentage of water content of the stool are more important than the number of defecations. Constipation is either short-term and temporary or chronic. Constipation lasting longer than one month is considered chronic constipation. Chronic constipation may cause concern for families that it may be a sign of a serious illness. Especially in the first months of life, parents pay great attention to the frequency and characteristics of their children's defecation.

What is the Frequency of Constipation in Children?

Approximately 3% of preschool children and 1-2% of school-age children complain of constipation. In general, the incidence of constipation in children varies between 0.3% and 8%. However, in recent years, the number of patients admitted to paediatrics and paediatric surgery outpatient clinics due to constipation has been increasing gradually and it negatively affects the quality of life of the patient and the family.

How should normal defecation be in children?

For a normal defecation to take place, three intestinal functions must be functioning properly.

• Transport of intestinal contents from the stomach to the anus (butt), which is related to intestinal motility (movement).
• Emptying the last part of the large intestine (rectum) at certain intervals, i.e. defecation
• Retention of intestinal contents between defecation, i.e. continence.

How Does Defecation Physiology Work?

In the first year of life, defecation control is unconscious and involuntary as a reflex. From the second year onwards, cortical (brain) control starts to come into play. Defecation takes place with the contraction of the muscles of the anorectal region (around the buttocks) and the harmonious functioning of the sensory nerves. When food passes into the stomach, the gastro-colic reflex (reflex between the stomach and large intestine) is stimulated and the colon (large intestine) begins to contract. When these contraction movements come towards the last part of the large intestine (rectum), the muscles in the lumen of the rectum (levator ani and puborectal muscles) also begin to contract. These muscles are surrounded by the anal canal, internal (IAS) and external anal sphincters (EAS) in the last part we call the anus. The circular smooth muscle layer at the distal end of the rectum thickens 3-4 times to form the IAS. The EAS is made of striated muscles with connections from different regions. The tonic contraction of the smooth muscle of the IAS and the continuous tonic contraction of the puborectal striated muscle function together to make a right angle between the rectal axis and the anal canal axis. In this way, the rectum remains closed and empty at rest and faeces are retained.

Rectal pseudoreceptors are stimulated by stretching the rectum with faeces and pressurising the rectal wall and sphincter. Thus, afferent autonomic impulses travel through the myenteric plexus and reach the centre. The centre evaluates the impulses and transfers them to the conducting pathways and the sensation of defecation occurs. If the person is willing to defecate, transient voluntary contraction occurs in the EAS and puborectal striated muscles. Then, through the myenteric plexus in the lower part of the rectal wall, nerve impulses are passed distally and IAS relaxation occurs with reflex inhibition of IAS smooth muscles and recto-sphincteric relaxation reflex. This is followed by EAS relaxation. As a result, the angle between the anal canal and rectum axes increases and the anal canal opens. Faeces enter the anal canal. Meanwhile, pelvic pressure increases as a result of contraction of the diaphragm and abdominal muscles with straining and pelvic floor relaxes and faeces are expelled with striated muscle activity. The rectum and sigmoid are emptied with defecation.

What are the characteristics of normal stool?

The first stool of the newborn, ‘meconium’, is greenish black in colour, odourless, dense and sticky. Delayed passage in the first 24 hours may be associated with aganglionic megacolon, hypothyroidism, intestinal obstruction, meconium plaque, sepsis and maternal narcotic use. Passage may be delayed up to 48 hours in preterm or low birth weight babies.

Passage stools may be greenish-brown in colour, less dense, foul smelling and have the appearance of curdled milk. During this period, bowel movements may be absent or may occur 12-14 times a day, depending on the formula the baby is receiving.

Therefore, not only the number but also the appearance of the stool is important for constipation or diarrhoea.

Milk stools are seen after the first week. The stools of breastfed babies are homogenous, slightly sour smelling, light yellow, sticky and smeary in appearance. In this period, babies can stool after each feeding. It may rarely be light green and mucous. Stools of babies fed with cow's milk are tightly formed, pale-yellow in colour. It turns green-brown in contact with air.

What should be the normal number of faeces in children?

The number of defecations in children may vary according to the child's age, family habits and diet. Studies in children have shown that the frequency of bowel movements is very variable. It is normal for breastfed children to defecate 7-8 times a day or every 5-7 days. In 93% of breastfed or formula-fed babies, the frequency of defecation varies between 1-7 times a day, while breastfed babies defecate more frequently in the first days and at about 16 weeks of age, both groups defecate an average of 2 times a day. After four months and up to two years of age, it has been observed to decrease slowly from an average of 4 to 2 times a day. At the age of four years, 96% of children have a stool frequency between 3 times a day and 3 times a week. It should not be forgotten that breastfed babies may sometimes not defecate for up to 1 week without any clinical complaint. However, a physician evaluation is necessary to decide that this is not a pathological condition.

Normal defecation frequency in children;

Which criteria should be taken into consideration to say that the child is constipated?

The presence of at least two of the following complaints in the child is considered as constipation.

1. The child defecates less than three times a week.
2. The child has pain or excessive straining every fourth stool.
3. The stool is hard and/or in pieces every fourth stool.
4. The rectum is always full of faeces, whether or not the child soils the linen.

Table: Internationally recognised criteria for constipation

Which Children are at Risk for Constipation?

• Sedentary and sedentary life.
• Eating a diet without fibre.
• Consuming less water (liquid)
• Having anus and rectum surgery
• Having neurological disease

What are the Causes of Constipation in Children?

We can examine the causes of constipation under 3 main headings.

1. Functional constipation (lazy bowel): It is approximately 90-95% cause of constipation in children. There is no underlying basic disorder. It is generally caused by nutritional problems and/or faulty toilet training. There is no underlying anatomical, functional or metabolic problem in these patients. Most families state that constipation started when breast milk was stopped or when milk was added to the child's diet. Functional constipation, which is usually seen under 5 years of age, can often be explained as less than three firm and hard stools in a week.

2. Constipation due to organic causes (caused by a disease);

Anatomical disorders (anorectal stenosis, anterior ectopic anus, presacral mass, anal fissure and spinal cord diseases). Weakness of abdominal muscles is evaluated in this group.

3. Metabolic and Functional Problems: These are the main ones.

• Delayed defecation
• Not consuming enough water
• Low fibre diet
• Inactivity
• Sudden changes in life
• Early or late start of toilet training Psychological traumas
• Endocrine diseases
• Endocrine diseases
• Gastrointestinal system diseases
• Nerve and muscle disorders of the intestine
• Connective tissue diseases
• Some medications
• Dietary factors
• Functional disorders in the pelvic muscles
• Lactose intolerance (sensitivity to milk and milk products)

Can Psychological and Social Causes Cause Constipation?

One problem that can be encountered when toilet training starts is refusal of toilet training. These children urinate in the toilet but refuse to defecate in the toilet. When their nappies are tied, they defecate in their standing nappies. This situation can rarely last for years. These children are candidates for constipation. The thing to do is to fasten the nappy again, although some families are not willing. 89% of cases start using the toilet within three months. Children who tend to hide while defecating before completing toilet training are more likely to refuse toilet training, become constipated and retain their faeces.

When a careful history is taken in older children, more than 80% of them have a triggering stressful event (birth of a sibling, divorce of parents, death of grandparents, moving house, starting school). When the behaviours and attitudes within the family are examined, lack of autonomy in eating and sleeping habits as well as lack of autonomy in the child is a contributing factor. Since it is usually the father who sets the rules in our family structure, the lack of paternal authority may create a symbiotic relationship between the child and the mother. Depending on the age of the child, he/she may want to postpone the need to defecate when he/she is engaged in activities that he/she likes very much such as playing with his/her toys, playing games on the computer or when he/she cannot use his/her own toilet. Especially in school age, the lack of adequate school toilets (such as cleanliness, number of toilets, lack of separation between boys and girls in some places) may lead to children not using the toilet and this may lead to many problems including constipation. As a result, the vicious cycle mentioned above can start at any age.

What are the Symptoms of Constipation?

General symptoms of constipation; pain and difficulty in defecation, hard defecation, decrease in the frequency of defecation are the main symptoms. Symptoms that may occur if constipation lasts longer than 2-3 weeks;

• Loss of appetite
• Blood in the stool or nappy
• Difficulty and pain in defecation
• Abdominal distension
• Stools with a foul odour
• Prolapse of the mucosa from the anus
• Fever
• Urinary incontinence (usually in the form of urge, i.e. the child feels urine but cannot reach the toilet)

How is Constipation Diagnosed?

The most important diagnostic method is a good history and systemic general examination. Information obtained from the patient and his/her relatives is usually sufficient for diagnosis.

However, if there are findings suggestive of an organic cause, it may be necessary to take an abdominal X-ray, a medicated large bowel X-ray and sometimes a biopsy (piece) from the last part of the large bowel. For functional constipation (which is almost all constipation in children), it is usually sufficient to take a standing abdominal X-ray film in addition to the physical examination.

 

Thyroid hormone tests, calcium, magnesium and other electrolyte levels in the blood are laboratory tests to be checked to rule out diseases that may cause constipation. Complete urinalysis and urine culture should be checked especially in cases of constipation accompanied by faecal incontinence.

Is There a Classification of Constipation According to Stool Shape?

Yes, there is an international classification according to the shape of the faeces. The physician and the family should take this classification into consideration in the treatment.

 

 

What kind of problems does constipation in children cause when left untreated?

In the patient, it causes tears in the mucosa around the buttocks, which is very painful and the child does not want to poop and holds it. This situation causes the stool to harden even more and the event enters a vicious circle. These tears cause bleeding and the patient may come to the physician with a complaint of bleeding. The stool accumulates in the large intestine, hardens and causes what we call faecal impaction. Then it causes faecal incontinence in the form of overflow, which we call soiling. It causes psychological problems in older children and negatively affects the quality of life of the child and family.

In addition, when constipation is not treated, long-term anorexia-developmental retardation, abdominal pain, serious deterioration in the child's comfort, unhappiness, restlessness and consequent psychological disorders (social exclusion, depression and anxiety; especially if fecal incontinence is also present),

The bladder (urinary bladder) is located just in front of the last part of the large intestine. The full bowel presses on the bladder and the bladder constantly contracts as if there is urine inside and it is going to empty. This can cause a feeling of urgency and urinary incontinence in the child. In addition, failure to empty the urine properly and sufficiently can cause recurrent urinary tract infections.

Does Breast Milk Prevent Constipation?

Yes. Breast milk is the preferred food for the first six months. If ready-made formula is to be given, those containing fibre should be preferred. When supplementary foods are started, apricots, black plums and vegetables with olive oil can be given according to the season. Okra is very important in solving constipation. Between 6-9 months, broccoli, zucchini, celery, peas, and after 9-10 months, beans, chickpeas and lentils can be consumed from legumes.

Why do babies who are exclusively breastfed become constipated?

There may be several reasons for this;

• Food allergies, i.e. the effect of proteins from the food eaten by the mother.
• Genetic and congenital diseases affecting the intestine (Hirsprung's disease, congenital hypothyroidism, cystic fibrosis).
• Deficiency of electrolytes such as calcium, potassium and sodium in the blood due to various causes.
• And some medicines used by the mother.

How to Treat Constipation in Children?

First of all, if there is an underlying disease causing constipation, it should be treated. However, since the rate of these patients is low and requires special treatment, they will not be described here. Here, the treatment of functional constipation, which constitutes the majority of constipation in children, will be discussed.

As mentioned above, the most common causes of functional constipation are nutritional problems and incorrect toilet training. Therefore, treatment should basically be directed towards these. The treatment of a patient with chronic constipation should be well organised. The physician, the family and the child should accept that this may take a long time.

The cause of constipation must first be well understood, which is achieved with a good history and physical examination. This situation should be explained in detail to the family and, if possible, to the child. The child and the family should be encouraged that this will definitely improve when the treatment programme is followed. If there is excessive accumulation of faeces in the intestines, these should be emptied first. The necessary toilet training and good nutrition should be given. The programme and medication should be as little as possible to facilitate compliance with the treatment.

Some of the main criteria to be considered in the programme are as follows;

1. Regulation of nutrition:

The main criterion here is that the child should eat plenty of fibre and pulp foods. Because fibres cannot be digested and cause softening of the stool by drawing fluid into the intestinal lumen with mass effect. However, the main issue to be considered in nutrition should be the regulation of the nutrition of the whole family, not the child in the form of diet. Otherwise, the child will show resistance to this.

The family diet should include plenty of vegetables and fruits, chocolate etc. prepared foods should be avoided. The method for this is to exclude these foods from the home for a certain period of time. The daily intake of fibre is ‘age (years) + 5 grams’. The amount of milk and dairy products may need to be reduced in some children. At the very least, excessive consumption of milk and dairy products should be avoided.

2. Education:

Education of the child and the family (giving detailed information about the disease and reassuring the family and the patient). The family and the child should be informed by a physician who is an expert in the field about the child's daily regular visits to the toilet and the necessary training should be given. Behaviour change; increasing the time spent in the toilet after meals and rewarding method.

3. Medication

Evacuation of petrified faeces in the rectum; Mineral oils, magnesium citrate, lactulose, senna, polyethylene glycol solutions by mouth

Phosphate or mineral oil enemas used following rectal saline enemas. Since this treatment is painful, it should not be preferred except in compulsory cases.

Does Drinking Olive Oil Have Stool Softening Effect?

Olive oil can sometimes be useful, it does no harm, but it is usually not sufficient in treatment.

How should defecation be done and what kind of toilet should be used to avoid constipation?

Scientific research shows that defecation by squatting, which has been done for thousands of years, is the most physiological form. In other words, we should use alaturka (Turkish style) toilets, not alafranga (Frankish style) toilets. All studies show that the following diseases increase in people who use alafranga toilets in the long term.

• Constipation
• Anal Fissure
• Haemorrhoids (Haemorrhoids)
• Bowel inflammation
• Pelvic region diseases

 

Figure: 1. When we sit on the toilet, the intestines take an angled shape and this makes it difficult to empty the intestines.

Figure: 2,3,4 Examples of correct and incorrect toileting patterns.

If there is only a toilet bowl at home or in the area where we live (such as school, nursery, etc.), it should be arranged in a way that allows defecation by squatting, and appropriate stools should be used to provide physiology under the feet.

*** The information provided here, the content of the website has been organised for the purpose of informing the visitor and especially the families. No information should be considered as advice by visitors and should not lead to any decision or action. The patient should definitely be examined by a paediatric surgery specialist and should make a decision by consulting him/her and consulting his/her one-to-one information.