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Introduction

Constipation in children is a common disorder. About 10-30% of patients attending pediatric gastroenterology OPD (Outpatient Department) have the disorder of fecal elimination. Constipation is a well-identified and easily noticeable disorder in adults. However, it is not so easy to identify in children due to their infrequent/irregular bowel movements. It is more difficult to identify in the early phase of the present scenario because most parents work, and someone else takes care of their children. If this problem does not get attention at the earlier stages, it can lead to psychosocial disturbances in the child, decreased school performance, and growth failure. So, a simple disorder like this can lead to a devastating condition.

What Is Constipation?

A simple definition for constipation is "frequency of bowel movements less than 2 per week or passing of hard stools requiring excessive straining with or without the presence of blood in the stool." Normal stool frequency in children is 4-5 times a day in infancy and 1-2 times daily in toddlers. Constipation in children with harder and tighter stools than normal. It occurs only if the gastrointestinal tract is damaged or infected.

Types of Constipation:

• Organic Constipation - Poops are painful due to some diseases, and they are rare.

• Functional Constipation - It occurs in most children. Functional constipation occurs when the GIT is infected, and children must hold back normal bowel movements.

When to See a Doctor?

Most children's constipation is not very significant. On the other hand, continuous constipation could indicate an underlying illness or cause difficulties. If the child's constipation lasts longer than two weeks or has any symptoms, have them checked out by a doctor, like fever, loss of appetite, blood in the stool, stomach swells, losing weight, and pain in bowel motions.

What Are the Causes of Constipation?

Common Causes of Constipation:

• The large intestine absorbs water in the food, making the stool hard and dry.

• Colon muscle movement is decreased; when food enters the colon, it absorbs water in the food and forms stool. Movement in the muscle passes the stool into the rectum and the remaining water is soaked up, and the stool becomes solid at this stage.

• Training the child for the usage and necessity of the body. If toilet training turns into a struggle, children avoiding the desire to urinate and poop can easily turn into an uncontrollable habit.

• Antidepressants also produce constipation.

• Dairy products like milk, curd, and ghee cause allergic reactions and sometimes lead to constipation.

• Changes in the environment also cause constipation.

Causes for Constipation in Infants Include :

• Congenital malformation.

• Endocrine disorders.

• Dietary factors.

Causes for Constipation in Older Age Group Include :

• Anal fissure.

• Functional constipation.

• Dietary factors.

• Psychosocial factors.

• Rectal ulcer.

Clinical Features

• Passing hard pellets like stool requires excessive straining with or without decreased stool frequency or the presence of blood.

• Some children present with nonspecific abdominal pain. These children may withhold stool if there is pain experienced due to anal fissure or hard stool. This creates a vicious cycle. These children may have hard stools that block the toilet. These children may have retentive posturing and pass stools behind the door or sofa or curtain. If not diagnosed earlier, this can lead to decreased appetite and food intake and, subsequently anemia and growth failure. Untreated children may present with acute gastrointestinal obstruction in an emergency.

What Are the Symptoms of Constipation?

• Does not have bowel movements for about two to three days or a week.

• Pain in the stomach.

• Pain during the movement of the bowel.

• Stools become very small sometimes.

• Blood on the surface of the stool.

• Loss of appetite.

• Tiny wet or semi-wet stools on a child's underwear.

What Are the Methods of Investigation of Constipation?

• A proper history and evaluation of the onset of the signs and symptoms is the key to identifying the problem.

• Investigation depends on the age, duration, and suspected etiology of the individual child.

• It includes CBC (Complete Blood Count), biochemical profile, ultrasound abdomen, TFT (Thyroid Function Tests), barium enema study, and coeliac serology in suspected cases.

What is the Management of constipation?

• Management of local causes like anal fissures is done by sitz bathing (sitting in warm water such that only the hips and buttocks are in water) and with local analgesics and short-term laxatives.

• Management of psychosocial issues.

• Avoid eating junk foods, high fat, and low fiber foods.

• Take more green, leafy vegetables and fruits.

• Drink more fluids, like juices and water.

• Regular exercise and physical activity can help relieve constipation.

• The drug sorbitol is used, which acts as a mild osmotic laxative.

• Diet modification - dietary management in the form of a high-fiber diet and an adequate amount of water.

• Laxative - The use of laxatives depends on the duration of the illness.

• In acute cases of constipation (2 weeks to 2 months duration), pediatricians give short-term laxatives (lactulose for 2 weeks) to relieve symptoms, and then dietary management has to be continued.

In chronic cases of constipation (more than 2 months), we need to identify if there is impaction of stool (fecal impaction is hard stool stuck in the rectum due to chronic constipation). If there is no impaction, use Polyethylene glycol (PEG) as an osmotic laxative for at least 6 months; titration of the dose is required during follow-up. If fecal matter is impacted, first we need to do disimpaction by saline enema, then continue polyethylene glycol for at least 6 months.

How to Prevent?

To some extent, it is preventable by good toilet training starting at 12 to 15 months and by regularizing the bowel movements. Toilet training is the art of teaching the child to make a routine defecation. Ensure the child sits in the toilet for 10 to 15 minutes daily during a fixed time, preferably in the morning after breakfast. Because eating something leads to an urge to defecate. So, one can take advantage of these reflex movements. Use a single word to indicate defecation; otherwise, the child may get confused about what to do, and actually, this is also a cause for constipation in children belonging to multilingual families. Another preventive method is dietary management through an adequate fiber diet.

Conclusion

Several things need to be clarified regarding the use of diets to treat newborn and young child constipation. For children experiencing repeated constipation, increasing fluid intake and adhering to a high-fiber diet are insufficient; in most cases, laxatives and behavioral modifications are also required for the management. Along with managing constipation, it is necessary to manage nutritional issues with multivitamin supplements.