Constipation has been defined as the decrease in the number of bowel movements that the child performs, the alteration of its consistency…
What is constipation?
Constipation has been defined as the decrease in the number of stools made by the child, the alteration of their consistency (hardening) or the size of the stools. This can cause an annoying sensation to the child due to unsatisfactory defecation, either because it bothers them when they do it, or because it’s done less often to the appropriate.
It’s a very frequent alteration in pediatric consultations, which although it appears in both sexes, usually has a slightly higher incidence in males.
In babies, the parameters of normality in the pattern of their intestinal habit vary as the child grows and are directly influenced by the type of feeding the baby has. Infants with breast milk, usually can make more than 4 stools a day, they even make a bowel movement after each shot, although this frequency can vary from one child to another. Children with artificial lactation usually have fewer bowel movements than those who have breastfeeding. In both cases, the intestinal habit can be modified by introducing complementary feeding. Thus, progressively during the first year, the number of habitual stools of the baby decreases, being able to be of approximately two stools per day in children after the first year.
What produces it?
90 – 95% of constipation episodes are of functional origin, that is, there is no disease or organic disorder that produces them, although this type of constipation can be influenced by a triggering factor such as:
- A change in diet, for example, moving from breastfeeding to artificial feeding, or at the beginning of a complementary feeding.
- Family history of constipation.
- Low fiber intake or inadequate hydration.
- Due to the appearance of an anal fissure or the presence of an infection.
- At the time of removing the diaper, etc.
The mechanism of production in these cases is usually related to an episode of pain in the defecation with harder stools, so the child produces an episode of fecal retention, which favors the hardening of stools, the distension of the rectal ampulla and the increase of the child’s fear of defecation due to the presence of pain. All this becomes a feedback wheel that prolongs constipation, since in addition, the physiological functioning of the perception of desire to defecate is altered in the rectum of the child.
In a small percentage, it appears associated with other organic diseases:
- Related to anatomical alterations: Anorectal malformations, tumors, atresia or anal stenosis, etc.
- Related to alterations of bowel motility: Hirschsprung’s disease, myopathies, neuronal dysplasia, etc.
- Neurological alterations: Myelomeningocele, cerebral palsy, neuropathies, spina bifida, etc.
- For the suffering of any metabolic, hormonal or immunological alteration: Hypothyroidism, diabetes, hyperparathyroidism, cystic fibrosis, hypercalcemia, celiac disease, etc.
- Due to the influence of psychological factors, sexual abuse, etc.
- Caused by the taking of certain drugs such as the chronic use of laxatives, medication with morphic derivatives, anticholinergics, iron, etc.
What are its symptoms?
Constipation occurs in the youngest as important irritability, associated with the appearance of intermittent abdominal pain, sometimes abdominal distension, retentive postures to endure the sensation of defecatory pushing in the presence of anal pain with defecation, the presence of very large stools, sometimes with presence of blood and hardened. In addition, they can increase gas, bloating and abdominal cramps.
The number of habitual stools of the child diminishes or are still done daily but incompletely, presenting episodes of expulsion of hard stools accompanied by more pain.
In addition, there may be an alteration of the child’s appetite, presenting anorexia and with it weight loss and weight gain. Occasionally, a urinary infection or an uncommon complication appears, a rectal prolapse (the rectum slips and exits through the anus).
The doctor can assess the presence of chronic evolution constipation of functional origin based on the presence or absence of symptoms and signs in the child, collected in the so-called Rome III Criteria. As diagnostic criteria, in this case for children from 0 to 4 years, the presence of 2 of the following manifestations is determined during a month:
- Two or fewer bowel movements a week.
- At least 1 episode of fecal incontinence a week, in a child who controls sphincters.
- Excessive stool retention.
- Painful or difficult defecation.
- Presence of a large fecal mass in the rectum.
- Large diameter stools that can clog the toilet.
How is the diagnosis?
The diagnosis of constipation is basically clinical, based on the questioning that the pediatrician performs to the parents or caregivers of the baby: How was the onset of constipation, characteristics of the stools, type of breastfeeding and complementary feeding, family history, associated symptoms that may appear in other related diseases, etc. This is accompanied by the physical examination of the patient, with special attention to the palpation of the child’s abdomen, to detect palpable masses that may correspond to the accumulation of feces, pain, presence of anal fissures and rectal prolapse; evaluation of the fecal impaction in the rectal ampulla, evaluation of the anal sphincter, presence of lesions, auscultation of abdominal noises, etc.
In infants, a phenomenon called infantile dyschezia may appear, from which a differential diagnosis must be made as it’s a process other than constipation. It’s an alteration that appears in children under 6 months of age due to the immaturity of the digestive system leading to a lack of coordination between the desire to defecate and the relaxation mechanisms. For a few minutes the baby may have pain, facial flushing, crying, and trunk movements until being able to perform the normal deposition.
In certain occasions, to make a differential diagnosis regarding the possible secondary origin of constipation, the doctor may request to do some additional test to the baby, such as an abdominal x-ray to see the presence of fecal mass in the colon and rectal ampulla, assess the lumbosacral column, etc. In other cases, a blood test is performed to detect hormonal or metabolic alterations. If there is any suspicion or diagnostic doubt, the doctor can indicate the need of an anorectal manometry for the study of the motor functioning of the rectum and in more selected situations, to make a barium enema or a rectal biopsy.
Which is the treatment?
Once the diagnosis of constipation and its possible cause has been established by the doctor, the initial treatment is aimed at releasing the fecal matter. This usually remains in the rectal blister and usually causes pain when the child tries to push the fecal matter. For this, depending on the age of the baby, the pediatrician can stimulate the baby with a probe or glycerin suppository or using a saline enema, magnesium salts or the use of polyethylene glycol can also be helpful. In children older than 6 months the oral route is usually preferred instead of the rectal route. With the release of the hardener fecal matter, the effectiveness of the posterior treatment is favored in the medium term and an adequate treatment should be maintained until the child acquires a regular intestinal habit and stays stable.
After the release of the hardener fecal matter, according to the characteristics of the constipation, the age of the baby and the possible alterations associated with it, the pediatrician can indicate the use of laxative and softening drugs, with different action mechanisms (osmotic, non-absorbable sugars, mass formers , emollients, etc.), in certain doses and treatment length. The guidelines for the administration of medications must always be indicated by the doctor, since depending on the months the baby has, some or other drugs may be used.
In cases in which there are associated complications such as anal fissures, perianal dermatitis, etc. the pediatrician will add topical treatments with corticosteroids or antibiotics, according to the appropriate indication in each case.
The withdrawal of the treatment is usually done progressively, enhancing the measures that should accompany the drugs for the prevention of the reappearance of constipation: adequate hydration, breastfeeding, use of artificial formulas of lactation with probiotics, cereals enriched with fiber, vegetable and fruit porridges and varied complementary feeding rich in fiber, acquisition of a stable regular habit in children who control sphincters (for example, try to make the child go to the bathroom after meals to take advantage of the gastrocolic reflex or intestinal stimulus that occurs at that moment), favoring proper postures, abdominal massages, etc.
It’s important that parents or caregivers know the constipation mechanisms, keep calm and have patience, making positive reinforcements to the child.
In case of a non-desired response to the treatment, complications appear, diagnostic doubts, etc. your main pediatrician can refer the baby to be evaluated by a pediatric gastroenterologist at the hospital.
To prevent the occurrence of constipation episodes that might perpetuate over time, it’ essential that parents, caregivers and the primary care pediatrician, pay special attention to monitor the bowel habits of the child especially in those circumstances in which its most likely that constipations may appear: Introduction of artificial lactation, introduction of complementary feeding, solid foods, toilet training, etc.
It’s important for parents to know the usual mechanism by which functional constipation is usually perpetuated, to understand what happens to the child and to adapt in a regulated way the adequate hygienic-dietetic measures in a constant way. Maintain patience, transmit calmness to the child and make positive efforts with every day’s achievements.
Whenever possible, breastfeeding should be encouraged and in children who already have complementary feeding, stimulate a proper, varied and fiber-rich diet according to the indications for its age. Don’t forget adequate hydration to prevent the hardening of stools. Stimulate movements and physical activities such as crawling, walking… for the development of the abdominal girdle musculature and bowel movement. In addition, rectal stimulation and the use of suppositories or enemas in babies should be avoided, as long as it’s not indicated by the pediatrician and avoid medicating the child without first consulting the doctor.