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What is constipation?

Children ages 1-4 typically have a bowel movement 1-2 times a day. Over 90% of this same group goes at least every other day. Children with constipation have bowel movements that are large, hard, dry and painful to pass. These stools may occur every day or may be infrequent. This condition is very common. At least 25% of visits to the Boys Town Pediatric Gastroenterology Clinic are due to problems with constipation.

What are the symptoms?

It can be normal to have a stool only infrequently. In some infants, difficulty in expelling a bowel movement (usually a soft one) can be due rectal muscles not relaxing at the right time. Some healthy breast-fed infants could skip several days before having a bowel movement. Simply having infrequent stools that are soft and painless, without other symptoms, is probably not a medical problem. Some children with constipation may not have any bowel movements for several days and then have a very large, hard stool which can clog the toilet. Patients may have rectal bleeding from tears called 'fissures." Some patients also have leakage of liquid, diarrhea-like stool. The medical term used to describe the soiling in a chronically constipated child is encopresis. Children may refuse to go to the toilet or may hide their stool in a private place. They may cross their legs, make faces, stretch, clench their buttocks or writhe on the floor. It sometimes seems that they are trying to push stool out but cannot. In most cases, they are actually holding the stool back.

Other symptoms include stomachaches, cramps, vomiting, nausea, bloating, cranky behavior, poor appetite, flushing or pallor, headaches and even weight loss. Some children with constipation wet the bed at night or even wet their clothing during the daytime. This wetting is called "enuresis." These children may have urinary tract infections because stool masses press on the urinary tract and can block normal urine flow.

What causes constipation?

Perhaps the child has had hard, painful stools. Some children naturally have dry, hard stools. A diet change, viral illness, hot weather or travel can lead to hard stools. A bad diaper rash can cause painful passage of stool. Older children may start holding bowel movements when they go to school or summer camp and are faced with a toilet that is less private than the one they have at home. At any age fear, discomfort or embarrassment can make a child try not to have a bowel movement. If this continues, the result is constipation. The initial cause may have occurred many years before the child is seen by a doctor for treatment of constipation.

Stool that is held back eventually fills up the colon and stretches it out of its normal shape. Stool retained in the colon dries out as the colon absorbs water from it. The longer the stool is left in the colon, the larger and harder it becomes, making bowel movements even more painful. This starts a vicious cycle. In the normal colon, muscles try to push stool out. Nerves tell the child that a stool needs to come out. However, the stretched-out, flabby colon muscles cannot push and the hard stool gets stuck. Sometimes only liquid can pass around the rock- like stool. Stretched nerves become less sensitive. The child may no longer realize that he needs to have a bowel movement and may be afraid to try to go.

How is constipation treated?

The treatment plan has three parts. First the initial cleanout clears the hard stool out of the colon. Second, maintenance therapy prevents future stool build-up and allows the colon to return to its normal shape and muscle tone. This is a time when the child is encouraged to have regular bowel movements in the toilet. Third, counseling may be helpful to structure the treatment plan and help gain the child's cooperation.

What happens during the initial cleanout?

The large, rock-like stool in the colon must be softened and broken down before it can be passed. We often times will use a medicine called magnesium citrate. This is a very strong laxative. We may also use large doses of Miralax, a stool softener. This is the medication that is used at lower doses during the maintenance phase of treatment. We only rarely use enemas or suppositories. These will only provide a partial solution to the problem since they only work with the magnesium citrate, but rarely alone. You are not on magnesium citrate for long because this type of strong laxative will tire out the muscles of the colon.

To decide if the cleanout is complete, you have to carefully observe the stools. At first, there should be large amount of stool or stool chunks. This may look like diarrhea because it is mixed with the laxative. After a while, less hard stool will come out and there will be brown tinged or clear liquid, signaling the end of the cleanout.

Pediatric Gastroenterology