Constipation Information

 

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JUDY DAVIS M.D.,F.A.A.P.

1095 E Warner Ave, #102

Fresno,CA 93710

Phone 559-412-8184  Fax 559-438-1174


                                              

CONSTIPATION:  INFORMATION FOR PATIENTS AND THEIR PARENTS



Definition:  Constipation is a very common pediatric condition which consists of passage of stools that are often hard, large and painful.  Children sometimes quit having regular bowel movements.  Instead they withhold and retain stools and don't completely empty the colon of feces.  This condition is so common that is one of the main reasons patients are referred to a pediatric gastroenterologist.  The exact percentage of children who have constipation is unknown, but it is safe to say that almost everyone experiences constipation at least once in their lifetime.  Children are often unable to understand or communicate their problem to their parents, so it can go untreated for a long time. 


Symptoms Which May Accompany Constipation:  Some children may not have any bowel movements for several days, while others continue having daily bowel movements.  Sometimes there can be frequent liquid stools that can be confused with diarrhea.  This occurs in the face of constipation because a large mass of stool collects in the rectum and the liquid stool above it leaks around it. 


In addition to the bowel problems, the patient may have stomachaches, cramps, vomiting, nausea, bloating, poor appetite and even weight loss.  Some children can develop hemorrhoids or anal tears (fissures) which can lead to blood in the stool and/or on the toilet paper.  Understandably, children with some or all of these symptoms may become irritable and unhappy.  The abdominal pain from constipation can be severe enough to mimic the pain of appendicitis and many children have been taken to the Emergency Room for this reason. 


1.Causes of Constipation:  There are many causes of constipation. It is often neither possible nor necessary to determine the cause for every child, but it is important to begin treatment once a diagnosis has been made.  For example, an infant changing from breast milk or formula (which typically produce soft stools), to a solid diet with less liquid may begin having firmer and larger stools.  Passage of these stools may cause pain and in order to avoid further pain, the infant may try to hold stools and prevent them from passing.  Holding these stools in the colon causes the stool to dry out and become larger and the passage of stool becomes even more painful.  Other children may start retaining stools after a bout with diarrhea which resulted in a painful diaper rash.  They will attempt to hold the stool because they realize that with passage of stool, it will irritate their rash and cause pain.  Occasionally children have normal soft stools until they are in hot weather.  Increased sweating may lead to dry, painful stools and then constipation.  Another cause of constipation is abnormal motility (movement) of the intestine caused by a viral infection.  A child may have a flu virus which initially causes diarrhea and after the diarrhea resolves, it is not unusual for the intestine to work improperly and produce large hard stools.  A diet which is low in fiber and high in refined sugars and  dairy may contribute to constipation.


Another important factor in constipation is inheritance.  Constipation may run in families for reasons for which we do not understand.  Thus, a child who has inherited this tendency from the mother or father may become constipated on a diet which would not cause constipation in another child without such a tendency.  Stress is another cause for constipation.  Some children react to tension by retaining stools, which causes them to become hard, dry and large.  In a similar manner, some children get involved in activities they don't want to interrupt and don't go to the bathroom when they need to and this, too, can lead to constipation.  Older children may start withholding bowel movements when they go to summer camp or school and are faced with a toilet which is less private than the one they have at home. 


Whatever causes the child to retain stool initially, the results are the same.  Retained stool starts backing up in the colon.  The stool will fill up the colon and start dilating it or stretching it out causing the muscles and the nerves in the colon to function abnormally.  The colon can't push the stool out as well as it used to and therefore the stools stay in the colon longer and they become harder and larger because the colon's function is basically to withdraw water from the stool.  A vicious cycle can ensue.  The large hard stool in the end of the colon may form an impaction and then the more liquid stool above it will pass around the impaction causing frequent soiling of the underwear with stool.  This can often be confused with diarrhea.  The nerves near the end of the colon which tell a person that stool is in the rectum and ready to be evacuated become less sensitive.  This causes stool to be passed inadvertently and without the child's knowledge.  If this problem continues untreated, the colon along with the muscles and the nerves in the colon may be permanently damaged. 


Treatment of Constipation:  There are two parts to the recommended treatment plan.  In the first phase, the initial clean-out, excess stool is cleared out of the colon.  This may be repeated whenever stools re-accumulate.  In the second part, maintenance therapy, the goals are to prevent stool buildup and to allow the passage of soft narrow diameter non-painful stools. 


I.The Initial Clean-out. 

a.Miralax/Glycolax/polyethyleneglycol.  Large rock-like stools have often formed in the colon and must be softened and broken down before they can be passed. Miralax is excellent for this purpose.  It can be taken by mouth and is not absorbed into the blood stream, nor does it stimulate the colon’s nerves or muscles, but rather stays in the intestine and causes more water to remain in the colon and penetrate into the stool to soften them.  The softer stool allows it to be passed out of the colon more easily. With Miralax, the patient cannot accidently be given an "overdose." .Miralax is safe for long term use.  Other medications such as magnesium citrate, Milk of Magnesia or lactulose can also be used.  However, these are more likely to cause side effects such as nausea or

Enemas alone or suppositories alone are not effective, because they only work on the

lower end of the colon (near the anus).  Thus, stool which is further up in the colon will not be cleaned out effectively.  Enemas provide only temporary relief.  Laxatives such as Dulcolax may help Miralax work faster, but this medication alone is ineffective in evacuating the colon of retained stool.  It is necessary to remove the excess stool from the entire colon so that the symptoms of abdominal pain, distention and nausea can be eliminated.  


Colon evacuation of retained stool with Miralax usually takes 1-7 days.  In order to determine when the clean-out is complete, the stool must be checked.  You will typically see lots of liquid and hard stool. Oftentimes you will be asked to bring your child back to the clinic to make sure excess stool has been evacuated and the impaction has been eliminated. 

Younger children may have to wear diapers during the clean-out.  It is not recommended that the child attend school or be far away from a bathroom while taking high doses of Miralax. 


b. GoLytely, CoLytely, NuLytely, Tri-Lytely:  These medications are liquid solutions used to clean the bowel more rapidly than Miralax.  They pass through the intestine and liquify the stool and as such, cause diarrhea but not dehydration. 


How to Use GoLytely, CoLytely, Tri-Lytely and NuLytely: 

     1.Add water to the fill mark on the gallon bottle.  Refrigerate for

             24-hours to chill.  You can add ice to make a slushy or sugar-free

             Kool-Aid or Crystal Light as flavorings to help improve the flavor. 

        2. Cap the bottle and shake the bottle vigorously several times to insure that the ingredients are dissolved.

        3. Drink 8-ounces of the solution as rapidly as possible every 10-20 minutes.  A loose watery bowel movement should result in approximately 1-4 hours, however, sometimes it may take 8-12 hours before stools appear.  Continue drinking until the entire contents of the gallon bottle have been consumed or as much as directed by the physician.  Initially the child may feel slightly bloated but will become more comfortable as the child continues to have periodic bowel movements.  Sometimes the solution will make the child feel nauseated and possibly vomit.  For this problem, a prescription of Phenergan at the following dose, __________________________, will be given to you.  The Phenergan should be started one hour before your child starts taking the GoLytely, CoLytely or NuLytely.  It's often helpful to use a timer and drink 8-ounces of solution every 10-20 minutes based on the timer, because the faster you drink it, the faster the evacuation will occur.  You can use other liquids after drinking the GoLytely to help remove the taste from the mouth.  It usually takes three to four hours to drink the entire solution.  The child must drink all the solution to achieve the best results. 


c.Magnesium citrate:  Magnesium citrate can often be used to dissolve retained stool and an impaction.  The dose of magnesium citrate for your child is ________________________________________ and should be continued for two to three days until just liquid and not solid stool is evacuated.  Your child must take a lot of fluid while on the magnesium citrate to prevent dehydration.  It's best to chill the magnesium citrate for 24-hours prior to drinking it or put ice in it.  You can certainly wash the taste of the magnesium citrate out of your child's mouth with fruit juice, soda, Kool-Aid or Crystal Light to improve the palatability of the magnesium citrate. 

       In most cases your doctor will ask your child to come back to the clinic to make sure        the retained stool and impaction have completely resolved before starting the          maintenance therapy.


II.Maintenance Therapy:  The goals of maintenance therapy are to prevent development of hard large painful stools and fecal retention.  The goal of this therapy is to maintain stools that are mashed potato in consistency and narrow in diameter and cause no pain with evacuation. 

a.MiraLax, Glycolax, Polyethylene glycol,Laxaclear.  This is a prescription and over the counter medication.  It is made of polyethylene glycol and it is not absorbed by the intestine, therefore it is very safe to use long term.  It softens the stool by preventing the colon from absorbing fluid from the stool.  The MiraLax powder is dissolved in non-carbonated, non-dairy fluid and it is virtually tasteless.  Your child's starting dose is ____________in ____ ounces of fluid ____ times daily.  It can be increased every 5-7 days as needed to achieve mashed potato in consistency stools. 


b.Milk of Magnesia.  This is a non-prescription medication.  The magnesium causes water to remain in the colon and thereby softens the stool.  Some magnesium is absorbed by the body and if large doses are given, magnesium toxicity can occur.  Your child's dose is ________ ____ times a day.  The dose can be safely increased to a maximum of _______ ____ times a day. 


c.Sorbitol, Kristalose or lactulose are prescription medications.  These are non-absorbable sugars, which soften the stool by causing more fluid to remain in the colon, and the side effects of these are gas, abdominal bloating and abdominal pain in some children.  However, most children tolerate these medications well.  These medications can be taken by themselves or added to any fluid (soda, juice, chocolate milk, etc.) to improve palatability.  Your child's dose is _________ _____ times a day.  It can be increased by _______ _____ times a day every week as needed to cause mashed potato in consistency stools.


d.Mineral oil is a non-prescription medication.  It lubricates the stool and intestine and is not absorbed by the intestine; therefore it is safe for long-term use.  It's only problem is unintentional leakage (orange staining of the underwear and clothing) in-between bowel movements when the dose of the mineral oil is too high or when an impaction has recurred.  It is normal to see orange material in the toilet water with the stool.  Your child's dose is _________ _____ times a day.  It can be increased by ________ _____ times a day every week as needed to cause mashed potato in consistency stools. 


e.All of these medications may need to be adjusted to your child's needs and it may take 2-4 weeks to get the appropriate dose for your child.  Your child's dosage may change if your child gets a gastroenteritis causing diarrhea (in this case the medication may need to be stopped).  The dosage may need to be changed if your child's dietary habits change, i.e., increased dairy intake, may cause firmer stools and the dose may need to be increased. 


f.If your child was toilet trained before developing constipation, he or she should sit on the toilet for 5-minutes twice a day, preferably following meals.  After meals is the best time because people have a gastrocolic reflex which causes them to have a bowel movement when the stomach is filled.  Younger children should be given a box or a stool to place under their feet while sitting on the toilet to help lower the pelvis into optimal position to have a bowel movement.  Reading or listening to the radio may help pass the time.  Prolonged toilet sitting over 10-minutes should be avoided as this increases hemorrhoid formation.  If the child was not toilet trained before developing constipation, this is usually not a good time to begin training.  It is best to delay toilet

                   training until the child has forgotten about the pain associated with bowel movements.  This may take up to six months. 

g.Increase dietary fiber for children who are eating table food by increasing bran, bran cereals, whole grain breads, fruits, vegetables, nuts and seeds.  This will promote bulkier, but softer stools which are easier and less painful to pass.  Children who are not able to increase fiber in their diet by eating these foods can take fiber medications such as Metamucil wafers or capsules or drink, Citrucel, Benefiber, FiberCon tablets or Equalactin tablets.  These are non-prescription items that can be bought at most pharmacies. 


h.Increase all fluids in the child's diet, especially water. 


i.Increase the child's physical activity if it's below average for age.  This helps

                  stimulate a sluggish intestine. 


j.It is important to avoid enemas and suppositories as much as possible.  They are often frightening for children and uncomfortable.  They only provide temporary relief because they only help evacuate the left side of the colon. 


k.Older children must be encouraged to be responsible for their own actions.  This includes taking the medication, sitting on the toilet twice a day for 5-minutes, complying with the dietary changes and cleaning soiled clothing. 


l.An older child with severe constipation secondary to stress or tension may need the services of a child psychotherapist or other counselors.  A child with constipation and fecal soiling may have a shorter time to resolution of the problem if behavioral modification techniques in conjunction with a child psychologist are provided. 


III.Success:  Constipation is curable!  Almost all children who follow this recommended treatment plan can resolve their constipation and be taught to prevent further episodes.  One of the major problems is regression.  Initially patients control their constipation with the above methods, but months or even years later start having constipation problems again and stool buildup.  If this happens, it is important to begin treatment sooner rather than later.  While children and their family are learning to control the problem of constipation, we are always available to provide support and assistance with the problems.  Please do not hesitate to phone us if questions arise between office visits.

Judy J. Davis, M.D., F.A.A.P.

Fellow American Academy of Pediatrics

Fellow Sub-Board American Academy of Pediatric Gastroenterology

American Board of Nutrition

Clinical Professor, Department of Pediatrics, University of California,    San Francisco

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