Age-related problems with bowel function can be classified as those affecting new-borns and infants, those affecting toddlers and preschoolers, and those affecting school-aged children. Fortunately, some of these problems can be prevented.
Newborns and infants
Infrequent stools during the first few weeks of life in a breast-fed baby who is not gaining weight suggest inadequate milk intake. On the other hand, it is normal for a healthy, thriving, breast-fed baby to have only one bowel movement every 7 to 10 days. Both these situations are often interpreted by the parents as constipation. Even more parental concern is triggered by the baby straining and turning red to produce a normal, soft bowel movement. Treatment with suppositories, rectal stimulation, or formula changes is often initiated by parents – with or without a physician’s guidance. Longstanding perceptions of abnormality can result. Early education on normal bowel patterns can prevent parental anxiety and inappropriate treatment.
A change from breast or formula feeding to regular cow’s milk can lead to constipation with painful defecation of hard stools. Febrile illnesses with dehydration can also cause hard stools. A severe diaper rash can similarly cause anal irritation and discomfort during defecation. In all these circumstances, a vicious circle results of pain with defecation, avoidance of passing stool, further hardening of retained stools, and more pain with defecation (pain retention cycle). Retention of stool can lead to abdominal pain, anorexia, and lethargy, and finally encopresis.
If recognized early, this problem can be easily treated with mineral oil or stool softeners. These must be given long enough that the child does not associate defecation with pain. After improvement, treatment should be gradually withdrawn over a period of several months.
Toddlers and preschoolers
Resistance to toilet-training can also initiate the pain retention cycle. Fear of the toilet and fear of falling into the toilet are sometimes a problem, which can be ameliorated by providing firm support for the feet with a proper footstool.
Psychologic factors can lead to the same problem. Illustrative examples are reported in the literature: a 3-year-old boy became constipated and refused to use the toilet after he saw a television commercial in which a toilet bowl turned into a monster. In another case report, severe defecation problems lasting for years developed in a 3-year-old girl whose mother had a colostomy. Mother had discussed this openly with her daughter, demonstrating the stoma and how it worked. Sexual abuse can also cause fear of painful defecation.
Existing bowel problems often get worse when a child starts school. Even previously normal children can develop problems. A more hectic daily schedule and the lack of privacy in school toilets sometimes lead to suppression of the urge to defecate, stool retention, and hardening of stools. Parents often know very little about their children’s bowel habits at this age, and children may be extremely reluctant to talk about them.
Lifestyle counseling is important in this situation. Getting up 20 minutes earlier in the morning will allow the child enough time for an unhurried breakfast and toilet time. Dietary counseling should emphasize the importance of a fiber-rich diet. Fresh fruits and vegetables, dried fruits, whole-grain cereal and breads, and unprocessed wheat germ and bran should all be encouraged. Unbuttered popcorn is a good source of fiber that children enjoy.
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