Constipation occurs in approximately 5% to 10% of children; it accounts for 3% of visits to the pediatric outpatient clinic and 25% of visits to a pediatric gastroenterologist. Defined as difficulty in passing stools; passing hard, dry, or unusually large stools; or infrequent defecation, constipation is sometimes associated with pain and a feeling of incomplete evacuation. The normal frequency of bowel movements has been characterized for infants and children as follows: Newborns have, on average, four stools per day the first week of life, with frequency decreasing to 1.7 and 1.2 stools per day around ages 2 and 4, respectively. Infrequent defecation can be defined as fewer than three stools per week; however, stool frequency varies according to the individual. Parents should try to recognize an increase or a decrease in stools based upon the child’s normal frequency—not on the frequency of other children. Clinical signs of constipation include pain localized to the periumbilical area, loss of appetite, and abdominal distention. Younger children may actually scream in anticipation of defecation. Serious complications such as an anal tear, fecal soiling (encopresis), impaction, rectal prolapse, and recurrent urinary tract infections can result from chronic constipation. If the child has blood in his or her stool or problems with uncontrolled urination, then parents should be advised to call their pediatrician.
Lack of dietary fiber or inadequate fluid intake are common causes of constipation, especially in infants. Underfeeding or converting from breast milk to formula or from baby food to table food may alter bowel function. Constipation may occur in children who delay defecating. This delay could be attributed to memories of painful defecation, a reluctance to stop their current activity in order to void, or a fear of public or school bathrooms. When the urge to defecate is repeatedly dismissed, the brain may become less responsive to the signal, which may lead to complications. Irregular bowel habits may also have an emotional component, such as parental expectations during toilet training in young children. Sometimes parents put too much pressure on children to “act like big boys and girls,” which can actually delay training or make training more difficult.
Constipation can also result from a concurrent illness. In addition, there are numerous medications that may cause constipation. Other possible etiologies include an underlying neurogenic, metabolic, or endocrine disorder, but in these cases patients typically have additional, concomitant symptoms.
Treatment of Constipation in Children
Managing constipation involves treating the underlying cause. Pharmacists can provide information on dietary changes. For infants, adding light or dark corn syrup to daily feeds (one to two teaspoons per feeding) or malt soup extract (liquid formulation for bottle-fed infants) may increase bowel movement frequency and soften stools. The amounts vary as follows:
• Formula-fed infants: 1 to 2 teaspoons in formula daily for three to four days;
• Breast-fed infants: 1 to 2 teaspoons in 2 to 4 oz of water twice daily for three to four days.
Increasing intake of fluids or juices such as apple, pear, and prune may be beneficial because of the sorbitol and carbohydrate content. Prunes, figs, raisins, bran, and beans add fiber to a child’s diet. Fresh fruits and vegetables increase bulk. Unbuttered popcorn is also a good bulking agent in older children.
Appropriate toilet training may help with relieving constipation. This includes having the child sit on the toilet for 10 minutes around the same time daily, preferably after a meal, regardless of whether the child has the urge to defecate. It allows the child to develop a routine. Proper positioning is important, as a child’s feet need to be firmly placed on the ground or a step stool to provide abdominal support during defecation. It is important to note that some children are not able to control their bowels until about age 4. Therefore, undue pressure should not be put on the child to do so. Pharmacists and other health care providers should encourage parents to have a positive, supportive attitude toward the child and training therapies.
If a child experiences a decreased frequency of stools and the parent requests a pharmacological agent, glycerin suppositories can be recommended. Glycerin pulls fluids into the colon and stimulates evacuation, usually within 30 minutes. The suppositories are available in infant and children sizes without a prescription. Other laxatives, such as stimulants, should not be recommended without the advice of a pediatrician or pediatric gastroenterologist. Mineral oil should not be administered to infants, due to the risk of aspiration. Enemas are not recommended for children younger than 2. It is important to refer a child to a pediatrician if he or she experiences severe stomach pains or cramping, consistently requires pharmacologic agents for defecation, or does not have a bowel movement following administration of OTC medications.