Constipation in Children – Symptoms and Treatment

Definition and Causes

Visiting a pediatric gastroenterologist becomes more common due to complaints of delayed bowel movements in children. Constipation is a disorder in bowel cleansing function, where the interval between bowel movements increases, stool consistency changes, and incomplete bowel movements occur regularly. In healthy children, the frequency of bowel movements may vary depending on the child’s age, quality of nutrition, water intake, and other factors. For example, in the first months of a baby’s life, who is solely breastfed, bowel movements may occur between 1 to 6-7 times a day. As solid foods are introduced, bowel movement frequency decreases, and stool becomes denser. With formula feeding, bowel movements are less frequent than breastfeeding. If compared to older children, the natural frequency of their bowel movements can range from 3 times a day to 3 times a week.

Parents often begin to notice this problem late, as the child seems fine, enjoying play and food, and tolerating the situation. While younger children are monitored, teenagers often feel embarrassed to discuss bowel disorders. Often, this is identified during a visit to a gastroenterologist due to another issue.

Causes of Constipation:

• Neurological causes: Disorders in the autonomic nervous system, spinal cord communication, psychological, and emotional disorders.
• Suppression of natural bowel urge: If a child is in an inconvenient place or position, they may suppress the urge and endure until they reach home. If this happens frequently, receptivity diminishes, intestines expand, and constipation may develop.
• Infectious diseases, leading to maturation disorder or death of the nervous tissue of the digestive system, also leading to decreased sensitivity of intestinal walls.
• Nutritional and feeding issues: The most common cause of constipation. Excessive consumption of processed products, lack of fiber, dietary irregularities, and fast eating can affect digestion and food discharge. Additionally, feeding a child with mashed food for an extended period, which inhibits chewing development, can lead to constipation at an early age.

• Hormonal disorders: Disorders in the secretion of hormones from the adrenal cortex, thyroid gland, and adrenal medulla.
• Use of specific medication classes: Medications that reduce bowel emptying function such as ganglion blockers, anticholinergics, sedatives, and others.
• Existing medical conditions: Rectal colon diseases and intestinal obstruction, leading to pain during defecation (fissures, hemorrhoids, fissures).
• Social and psychological factors: Environmental changes, absence of usual relaxation for defecation, and lack of hygiene. Children may fear defecating during toilet training. Unusual conditions in pre-school and school-age, like absence of individual restrooms and presence of strangers, can affect the ability to defecate normally.

Symptoms of Constipation in Children:

• Decreased frequency of bowel movements.
• Incomplete emptying of the bowels.
• Hard, pellet-like stools.
• Pain during bowel movements.
• Inability to control bowel movements (fecal incontinence).
• Changes in stool appearance (such as transitioning from mushy to solid).
• Abdominal bloating.

The frequency of bowel movements in children varies with age:

• In the first few months of life, bowel movements occur about 2-3 times a day if the child is breastfed and about 1-2 times a day if formula-fed.
• After six months of age, bowel movements occur about 1-2 times a day.
• After the age of 4-5 years, bowel movements occur once a day.

Despite the variation in bowel movement frequency in young children, the absence of bowel movements for more than one day should concern parents. However, it should be noted that passing stool every 2-3 days if soft and painless may be normal.

Constipation can present with local and systemic manifestations:

• Local manifestations include decreased bowel movement frequency, incomplete bowel emptying, and hard, pellet-like stools. These disturbances are often accompanied by pain during bowel movements and fecal incontinence.
• Systemic manifestations include fatigue, decreased appetite, headaches, and discomfort (fecal toxemia). Skin rash, pimples, and acne may appear on the skin.

During a medical examination, an increase in abdominal size due to gas accumulation may be detected, and palpation may reveal hard stool masses in the rectum and colon.

Delayed bowel movements may be accompanied by other digestive system disorders such as stomach and duodenal infections, gallbladder, pancreas, and functional disorders of the digestive and gallbladder system.

Based solely on clinical data, it is not always possible to determine the mechanism of constipation: is it due to muscle tension or weakness? However, constipation resulting from muscle weakness is typically more severe and persistent, with a progressive nature and may be accompanied by stool disturbance and stool stones.

The process of constipation development in children involves the following:

• Accumulation of stool masses in the large intestines for a prolonged period leads to increased absorption of fluid from them, making the stools denser. This results in damage to the mucous membrane and pain during defecation, forcing the child to suppress the urge to defecate.
• With repeated delay in defecation, the colon (sigmoid and rectum) expands, reducing the sensitivity of nerve endings, worsening constipation, and exacerbating it.
• Due to the increased expansion of the rectum, the tone of the anal sphincter muscle decreases, allowing liquid to pass around the compacted stool and leak through the external genital opening without defecation (encopresis).
• With the increased frequency of constipation episodes, there is a disturbance in the composition of beneficial bacteria in the intestines, exacerbating the condition.

Classification and Stages of Constipation in Children:

Classification by Origin:

• Primary Constipation: Resulting from congenital abnormalities in development.
• Secondary Constipation: Occurs due to diseases, injuries, medication effects, and others.
• Idiopathic Constipation: Disorders in bowel motility resulting from various causes, including inappropriate dietary factors.

Onset Time:

• Acute Constipation: Sudden absence of bowel movements for several days.
• Chronic Constipation: Regular decrease in the number of bowel movements for three months or more.

Classification According to the Type of Bowel Function Disorder:

• Excessive Muscle Constipation: Resulting from previous infection or psychological stress. It also occurs in cases of neuroses and psychological disorders leading to maintaining tension in the anal sphincter muscles and consuming fiber-rich foods.
• Inadequate Muscle Constipation: May accompany conditions such as osteoporosis, malnutrition, hormonal disorders (hyperthyroidism), and a sedentary lifestyle.

Functional Constipation:

• Accounts for more than 90% of constipation cases.
• Characterized by passing stool every 2-3 days with preserved urge, no abdominal pain, no cramps, and can be easily treated through nutrition.

Complications of Constipation in Children:

• Prolonged delay in defecation can lead to dilation and elongation of the large intestines, reduced blood flow, increased prevalence of hemorrhoids, anal fissures, and colitis, despite the common belief that these problems are related to adults.
• Repeated straining during defecation can lead to rectal prolapse.

Constipation stimulates and exacerbates the imbalance in intestinal bacteria, manifesting in reduced immunity in children, signs of nutritional deficiencies, bloating, and foul breath odor.

When constipation poses a threat to the patient’s life:

• Nausea and vomiting (signs of toxicity).
• Delayed urination (due to pressure from fecal masses on the urinary tract).
• General weakness, vomiting, fever, nausea, rapid heartbeat – signs of intestinal obstruction, peritonitis, which require immediate surgical intervention.

Diagnosing constipation in children:
When consulting a doctor if:

• Bowel movements are absent for more than three days accompanied by abdominal pain.
• Defecation causes rectal prolapse, hemorrhoids, or fissures in the rectum.
• Stool contains blood and mucus.
• Abdominal bloating and gas discharge disturbances are observed.
• Fever rises accompanied by abdominal pain and vomiting.
• Defecation is difficult for more than three weeks.

Medical history collection:
The doctor asks the following questions during the medical history collection:

• What type of food does the child eat? Does he consume vegetables and fruits? Does he drink enough fluids?
• How physically active is the child? Does he engage in active play?
• Are there any accompanying problems in the digestive or nervous system?
• How long has the child been suffering from constipation? What measures have been taken in this regard, and have they been effective?

Physical examination:
The examination begins with a rectal examination, assessing the extent of bowel filling, the condition of the anal sphincter muscle tension, the presence of any anatomical damage (fissures, stenosis), and the presence of bloody secretions. Anal sphincter muscle tension is high in Hirschsprung’s disease and low in cases of chronic constipation and cloacal anomalies.

Laboratory diagnosis:

• Stool analysis.
• Stool analysis for bacterial culture.
• Complete blood count and biochemical analysis.

Radiological diagnosis:

• X-ray imaging and contrast radiography of abdominal organs to visualize the structural and functional characteristics of the intestines.

Differential Diagnosis:

When making the diagnosis, it is particularly important to conduct a comparative analysis of diseases and similar clinical conditions to constipation. Firstly, it is necessary to exclude diseases that involve organic changes (such as Hirschsprung’s disease or absence of nerves in certain areas of the colon). In this case, there is a disruption in nerve supply to a portion of the colon, which can be congenital or acquired. Congenital absence of nerves manifests since birth, while acquired absence of nerves can occur after certain infectious bowel diseases. The longer the duration of nerve disruption in a portion of the colon, the faster the disease progresses and becomes more severe. In the case of Hirschsprung’s disease, traditional treatment is ineffective, and constipation worsens with the formation of fecal stones, increased abdominal size, and the development of colitis. The treatment for this disease is surgical.

Treatment of constipation in children:

Lifestyle and Behavioral Changes:

• Encouraging physical activity through walks, participating in sports activities, and outdoor games.

Dietary Guidelines:

• Increasing fiber intake in the child’s diet, focusing on fiber-rich foods such as whole grains, vegetables, and fruits.

Increasing Fluid Intake:

• Fluid intake should be monitored during constipation treatment, as water is necessary for stool formation and facilitating its passage in the intestines.

Pharmacological Treatment:

• Using probiotics (such as “Diwvalac” and “Portalac”) and targeted antibiotics (such as “Hylak forte” and “Eubicore”) as constipation treatment.
• Yellow bile drugs: (Cholosas, Chophytol, Galstena)
• Taking laxatives cautiously according to the prescribed dosage and avoiding prolonged use.
• Biofeedback therapy (training to control pelvic floor muscles) and physical therapy (such as electrical currents and equipment therapy) can help in constipation treatment.

Biological Therapeutic Intervention for Digestive System Control:

• It aims to enhance the child’s awareness of controlling gastrointestinal functions.

Reminder: It is important to consult a doctor before starting any constipation treatment in children, and medical guidance should be followed carefully to ensure treatment safety.

When a child experiences constipation, the following should be avoided:

1. Not punishing or forcing them to sit on the toilet harshly.
2. Avoiding certain types of foods that inhibit bowel movement, such as pears, pears, and dandelions. The amount of flour and meat-based food should be reduced.
3. Providing emergency measures such as giving laxatives, inserting a suppository, or performing a cleansing enema before visiting the doctor.

How to perform colon cleansing for a child:

• Colon cleansing is performed to clear the lower sections of the intestines from waste.
• Colon cleansing can be done at home, but it is preferable to have supervision from a healthcare provider.
• The place where the procedure is performed should not be cold, and the liquid used should be heated to a temperature between 22 and 26 degrees Celsius.
• The infant should be placed on their back, while older children should be placed on their left side.
• The tip of the suppository should be lubricated with petroleum jelly or baby cream, then gently inserted into the anus for a distance ranging from 3 to 7 cm, depending on the child’s age.
• After removing the suppository, pelvic muscles should be compressed for a few minutes.

Teaching the child how to empty the bowels:

• Biological training therapy to regulate pelvic floor muscles is considered an effective method in case of pelvic floor muscle dysfunction.