Bowel problems and how to treat them

What is constipation?

Constipation is the most common bowel problem in children. It is the inability to do a poo regularly or to completely empty the bowel.

Constipation is the most common bowel problem in children. It is the inability to do a poo regularly or to completely empty the bowel.

It can start at any age (including babies) and affects up to 30% of all children. It's particularly common among toddlers and pre-schoolers.

A child is constipated if they poo less than four times a week.

Constipation can be very uncomfortable and distressing for a child and difficult for the family to deal with.

How does the bowel work?

(Image: Blausen.com staff)

In order to explain why your child is having poo problems, it helps to understand how the bowel works.

Food goes in

The food that we eat gets chewed into little pieces which are easy to swallow. When it enters the stomach, the food is mashed up even more and is turned into a soupy mixture. This then passes to the small bowel (or small intestine) where the nutrients are taken out and used by the rest of the body.

Waste is produced

The waste liquid - watery poo - then goes further down the digestive system to the large bowel (or large intestine). The large bowel has strong muscles which squeeze the poo along. The body absorbs water as the poo is squeezed along, so that it turns into a soft, smooth, sausage-shaped poo.

Poo reaches the rectum

When the poo reaches the rectum, the lowest part of the bowel, the rectum stretches and a message is sent to the brain saying you need to do a poo.

A child with a healthy bowel can pass soft poos (Type 4 on the Bristol Stool Form Scale) at regular intervals without pain or discomfort at least four times a week.

When things go wrong...

If a child doesn't act on their body's signal that they need to do a poo, maybe because they've experienced a painful poo in the past, poo can build up in the large bowel. The longer the poo stays there, the more water is absorbed, and the harder and bigger the poo gets.

If the poo stays in the rectum, the rectum stays stretched, and the ‘I need a poo!' message is no longer sent to the brain. So your child might have no idea that they need to do a poo!

Soiling

Meanwhile, more liquid poo from higher up the bowel can leak around the hard lumps of poo and might even leak out of the child's bottom – this is called soiling or overflow. This poo might be runny, so you might think your child has diarrhoea, or it might be hard little bits, or both.

Early identification is important

It's easy to miss the signs of constipation, so the condition is often left untreated, misdiagnosed, or not treated properly. It's important to deal with constipation early to prevent the child from suffering unnecessarily and to stop it developing into a more serious problem possibly requiring treatment in hospital.

In England alone, there are 15,000 hospital admissions for paediatric cases of chronic constipation and urinary tract infections each year, 80% of which could be avoided, according to the National Institute for Health and Care Excellence (NICE).

For most children, constipation can be successfully treated. However, in some cases it can be a long and difficult journey; the child may need on-going support from health professionals and a lot of patience and encouragement from parents and carers.

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Published on Mon, 23 Nov 2020 10:42:36 GMT
Modified on Fri, 29 Jan 2021 15:06:32 GMT

For many children there is no underlying physical reason for what is causing their constipation. This is known as idiopathic or functional constipation.

Idiopathic constipation most commonly develops in children between 2 and 4 years old and has various possible causes including:

• Withholding poo (also called ‘stool withholding', which is when a child avoids emptying their bowels)
• Fear of the toilet (sometimes associated with pain or discomfort)
• Lack of a toilet routine (some children have such busy lives that it can be difficult to find time to sit and relax on the toilet each day)
• Resistance to potty training and an insistence that a nappy be put on to poo in
• An unbalanced diet
• Low fluid intake
• A change in routine
• Anxiety and emotional upset (for example when starting nursery or potty training)
• Some medications

When an underlying illness or condition has caused the constipation it is described as constipation with an underlying organic cause.

The following symptoms or signs could indicate that an underlying illness is the cause:

• Vomiting *
• Weight loss or failure to gain weight *
• A swollen, stretched tummy *
• Severe pain *
• A baby that does not pass its first stool (called meconium) within the first 48 hours of life
• Abnormalities of the anus
• Sores or ulcers near the anus *
• Neurological problems (such as weak or paralysed legs)
• Excessive thirst
• Urinary symptoms *
• Very pale-coloured poos

* These symptoms can also be caused by idiopathic/functional constipation however.

As there may be very little to see to suggest that that child has an underlying condition which is causing their bowel problems, it's very important for all children with constipation to have a physical examination.

For more information and help with this, see our continence assessment form and the constipation flowchart of the Children's Continence Pathway.

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For more information, please visit www.eric.org.uk

Published on Fri, 20 Nov 2020 16:45:46 GMT
Modified on Mon, 25 Jan 2021 15:20:35 GMT

How to treat constipation

For most children, constipation can be successfully treated. However, in some cases it can be a long and difficult journey; the child may need on-going support from health professionals and a lot of patience and encouragement from parents and carers.

For most children, constipation can be successfully treated. However, in some cases it can be a long and difficult journey; the child may need on-going support from health professionals and a lot of patience and encouragement from parents and carers.

If your child is showing signs of constipation, you should take them to the GP as soon as possible. The quicker they're assessed by the doctor, the easier it will be to treat the problem. Left untreated, constipation can become chronic, which is when it lasts more than eight weeks.

The GP's assessment

The GP will determine if your child has a poo blockage in their bowel by examining the abdomen. They'll ask some questions about your child's pooing patterns and do a general examination to rule out any underlying causes.

If underlying causes are found, your child will be referred to a specialist health professional for further tests.

If there are no underlying medical causes, this is called idiopathic constipation. The National Institute for Health and Care Excellence (NICE) recommends laxative treatment for idiopathic constipation that has lasted more than a few days (See NICE guidelines on constipation in children and young people).

The laxatives prescribed by the GP will help clear out your child's bowels of the built-up poo and help them start pooing regularly again. Depending on the age of your child and the severity of their constipation, they will need different types and strengths of laxative.

Laxative treatment & disimpaction

The NICE guidelines provide information on how to take laxatives correctly and explain how they clear out, or disimpact, the bowel. You can also read our factsheets: A Parent's Guide to Disimpaction and How to Prepare Macrogol Laxatives.

Children's laxatives are normally in powder form which should be mixed with water and then added to drinks or food.

Macrogol laxatives such as Movicol Paediatric Plain work by getting more water into the bowel, which keeps poos soft and easier to pass. Stimulant laxatives such as sodium picosulfate, bisacodyl, senna and docusate sodium encourage the bowel to push the poos out.

Children who don't have an impacted rectum will be prescribed a ‘maintenance therapy' using a macrogol laxative. If this doesn't get the poo moving, a stimulant laxative might be added.

If the rectum is impacted, higher doses of laxatives are needed which will fully clear out the bowel. You know the bowel is cleared out once the child passes brown water.

Many parents worry that the laxatives make the soiling problem worse, but it's important that the blockage is fully cleared. Stopping the medication too soon can result in the constipation recurring. After this, a smaller, daily maintenance dose of laxatives will be required.

The aim of the maintenance dose is to prevent poos from building up again. If the maintenance dose isn't followed, and the stretched rectum is not allowed to gradually return to its normal size, your child might become constipated again.

Laxative treatment may need to be taken for several months and shouldn't be stopped abruptly. Some children might need it for several years and a minority will require long-term laxative treatment.

Listen to our Helpline Podcast episode Chronic Constipation and Disimpaction to understand more about the process.

Changes to diet

You may need to make some changes to your child's diet alongside the laxative treatment to ensure they're getting enough fibre and fluids. For more information see our information on how to prevent constipation.

Developing a good toileting routine

Children who have chronic constipation often have trouble recognising when they need to go to the loo. This is because they lose the sensation of needing to do a poo when the rectum is stretched.

In addition to the laxative treatment, you should get your child into a good toileting routine. Encourage them to sit on the toilet at regular times each day, ideally 20-30 minutes after a meal. For more information look at our tips for establishing a good toilet routine.

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For more information, please visit www.eric.org.uk

Published on Mon, 23 Nov 2020 10:25:07 GMT
Modified on Fri, 29 Jan 2021 15:18:03 GMT

How to prevent constipation in children

The most important way to maintain healthy bowels is to drink lots of fluids. Keeping well hydrated ensures poo stays soft and easy to pass.

1. Drink plenty

The most important way to maintain healthy bowels is to drink lots of fluids. Keeping well hydrated ensures poo stays soft and easy to pass.

Children should have at least 6-8 drinks a day, preferably of water or a water-based drink like well-diluted fruit juice or squash. 2-3 drinks of milk a day are fine as part of a balanced diet.

The size of the drink will vary depending on their age: a 120-150ml cup is about right for a two year-old and a 150-175ml cup for a four to five year-old. Avoid drinks containing caffeine like tea, coffee and cola, and sweetened and fizzy drinks.

2. Eat a balanced diet

Having a balanced diet that includes fibre from fruit, vegetables, cereals (like oats, wheat and bran) and wholemeal bread also keeps the bowels healthy.

Fibre helps to retain fluid in the poo, keeping it soft and easier to push out.

3. Keep active

Exercise sends blood to the gastrointestinal tract which helps move food waste through the bowels quickly and easily. Running around and playing will help keep the bowels healthy.

4. Get into a good toileting routine

Children who have poo problems often have trouble knowing when they need to go to the loo so it's important to get them into a good toileting routine.

This should involve sitting on the toilet at the same times each day, ideally 20-30 minutes after each meal. This makes the most of the natural squeezing that happens after eating. Your child should also go to the loo before bed.

Other tips for the toileting routine are:

• Explain constipation to your child: This will help them to understand what's going on in their body and what needs to happen for them to get better. Take a look at our Poo and Wee section together and the books for children about poo problems available in our shop. Have a go at playing our poo game and singing Dr Ranj's Poo Song.
• Get into position: When they're sitting on the toilet, make sure your child's feet are firmly supported flat on a box or stool. Knees should be above the hips in a secure position. You might need a children's toilet seat to help with this. Your child should lean forward slightly, rest their elbows on their knees and gently push out their tummy.
• Make it fun! We need to relax to let the poo out, so distracting your child with toys, games and books whilst they're sitting on the loo can help. Keep these ready by the toilet, so they can sit for 5-10 minutes at a time.
• Stay relaxed: Gently rocking forwards and backwards and massaging the tummy in clockwise circles can help.
• Help the bowel muscles to push down: Laughing, coughing or blowing can help with this. Try blowing bubbles – then it's fun too!
• Give lots of praise for sitting on the toilet regularly and getting into a good routine. Your child obviously won't poo every time they go, but they should be praised for trying. For some children, being rewarded for every small, achievable step can make all the difference, so have a 'goody bag' of little, inexpensive rewards or treats at the ready.
• Keep a poo diary: This will help you record the different types of poo your child is doing and the time of day they do them (ideally the poo should look like a smooth sausage – Type 4 in the Bristol Stool Form Scale). By keeping a close eye on your child's poo habits, you'll be able to spot the signs of constipation early - download ERIC's Poo Diary to help track your child's pooing.
• Be patient: It will take lots of practice to get the poo in the loo!

5. Don't forget the bladder!

The bladder and bowels are closely related. If a child is constipated their bowel may be so full of stools that it presses against their bladder and causes bladder problems such as urinary tract infections (UTIs), urgency and frequency during the day, and bedwetting.

Content provided by ERIC.

For more information, please visit www.eric.org.uk

Published on Mon, 23 Nov 2020 09:48:43 GMT
Modified on Fri, 29 Jan 2021 15:19:42 GMT