Constipation in childhood

Constipation is a very common problem in childhood. It tends to occur between the ages of 2 and 4, and unlike in adults, it is slightly more common in boys than in girls. In most cases, the cause is functional, resulting from a change in diet or a decrease in fluid intake. Organic causes (such as anatomical, neurological, or metabolic disorders) are much less common and may require referral to a Pediatric Gastroenterologist.

Constipation is defined as the passage of hard and painful stools associated with a decrease in the frequency of bowel movements.

Infants under 6 months

Formula-fed infants usually have a bowel movement daily, sometimes less frequently. If the formula tends to cause constipation, you can try the anti-constipation version (AE) or switch to a different brand. The concentration of the formula should never be altered, meaning that the ratio of 30ml of water per scoop of formula should be maintained. From around two months of age, water can be offered between feeds. Abdominal massage in a clockwise direction and flexing the legs towards the abdomen (as shown in the image) can help with the movement of intestinal transit.

It is rare for an exclusively breastfed infant to experience constipation. First, it should be ensured that the baby is being adequately fed. The pediatrician or nurse will monitor the baby’s weight and look for signs of dehydration (producing fewer than 5 wet diapers a day, dry mouth, dry skin, etc.). Breastfed infants usually have a bowel movement after each feeding during the first month of life. After a month and a half, the frequency decreases, and several days or even a week may pass between bowel movements. This is simply because the baby is utilizing every drop of milk to grow and does not need to eliminate as frequently. This is not constipation.

Disquecia should not be confused with constipation either. Disquecia is characterized by a baby straining and crying for about 10 minutes before passing soft stools. This occurs due to a lack of coordination between intestinal movements and the relaxation of the pelvic muscles.

Infants over 6 months and children

A change in diet, such as the introduction of complementary foods (around 4-6 months of age), vacations, or starting to eat at school, can cause constipation.

The formation of hard and larger stools can lead to the development of a fecal impaction, filling up the rectum and causing a blockage. Sometimes, a constipated child may soil their diaper or underwear with liquid stool. This occurs due to overflow, where the liquid stool “overflows” the fecal impaction. The first step is to disimpact the rectum either through a rectal microenema or oral PEG (polyethylene glycol) packets, always under medical supervision. During the first few days after disimpaction, the intake of fiber should be monitored, as fermentation can produce gas, causing distension of the colon and pain. A 2-3 month cycle of PEG packets is recommended to regulate bowel movements and help the child overcome their fear of going to the bathroom. Once the impaction is resolved, and bowel movements are regularized, it is important to have a fiber-rich diet, but even more important is to maintain good fluid intake.

The passage of hard stools through the anus can lead to the formation of fissures, causing pain and distress in the child. This can lead to a withholding behavior due to fear of going to the bathroom. Fissures should be treated with healing ointments to break the vicious cycle of pain and stool withholding.

Prevention and treatment of constipation

1. A diet rich in fiber: offer natural orange juice on an empty stomach, kiwi, plums, pumpkin, whole grain pasta and rice (avoid unripe bananas and carrots). Fruits and vegetables are best consumed with their skin, as it contains the most fiber. Additional liquid fiber supplements can be purchased at the pharmacy.
2. Adequate fluid intake to transport the fiber throughout the intestine. This is crucial, as providing a lot of fiber without sufficient WATER is ineffective.
3. Do not exceed 500ml of milk (or 2 dairy products) per day.
4. Add a splash of olive oil to purees.
5. For older children (due to texture), mix 1-2 tablespoons of wheat bran into yogurt or purees.
6. Massage the abdomen in a clockwise direction using cream or almond oil to facilitate smooth movement.
7. If the constipation is severe and leads to a fecal impaction (a large mass of stool in the rectum), it can be resolved with a rectal microenema. After disimpaction, a treatment with PEG should be initiated for at least a month.
8. If the child experiences pain during bowel movements, they may have a fissure. It should be treated with a healing ointment.

When to call the pediatrician

1. If constipation lasts for more than one week.
2. If there is significant pain during bowel movements.
3. If there is blood in the stool.