What is functional constipation?
The rectum has two sets of muscles - the internal and external anal sphincters - that allow stool (poo) to pass out of the body. Normally, when stool enters the rectum, the muscles in the internal anal sphincter relax (stretch), telling your brain that you need to pass stool. You are not able to control the muscles of the internal anal sphincter. A person has an urge to pass stool when it reaches the external anal sphincter. You can control the muscles of the external anal sphincter, so if your child relaxes the external sphincter stool can leave their body.
In functional constipation, children withhold their stool by tightening their external sphincter and their buttock muscles (gluteal muscles) pushing stool back into their body, which makes them lose the urge to pass stool. This leads to stool building up in the rectum and relaxing (stretching) the internal anal sphincter, so it is always telling the brain that you need to pass stool. As the internal anal sphincter is always stretched, your brain ignores this message.
What are the signs of functional constipation?
You might recognize the signs of functional constipation if you see your child regularly:
- squatting
- rocking
- walking stiffly on their tiptoes
- crossing their legs
- sitting with their heels pressed against their perineum (the area just in front of their anal opening)
Is functional constipation harmful?
When your child withholds stool, their rectum and lower colon can stretch. This can lead your child to keep in stool much longer than normal. The longer the stool remains in the rectum, the more water it loses and the harder it becomes. The stool can then become "impacted" or packed into the rectum.
At the same time, your child's rectum can only hold onto a certain amount of stool. If the stool is impacted in the rectum, your child may experience accidental overflow soiling. This is when a small amount of stool which is often quite loose leaks out around the impacted stool and into the underwear. This is called encopresis. Your child cannot actually sense this is happening, as the stool is leaked out not pushed out. Naturally, this can be distressing for you and your child.
Constipation is common cause of lower urinary tract symptoms including incontinence, urinary tract infections and bedwetting.
How is functional constipation treated?
If your child has functional constipation along with accidental soiling, they will need to follow a treatment plan. The goal of this treatment is for your child to have a smooth, easy-to-pass, bowel movement (type 3 on the chart below) at least once a day without soiling.
Your child's treatment has two phases, or parts:
- a disimpaction (clean out) phase
- a maintenance phase
Disimpaction phase
During this phase, your child should drink lots of fluids and stay near a toilet. Make sure that these fluids include water and drinks containing electrolytes (sports drinks e.g. Gatorade, apple juice, orange juice).
To help your child empty their bowel, you will need to give them one or both of the following medicines:
- PEG3350
- Pico Salax
Your child's health-care provider will tell you exactly how much to give your child each day. You can make a note of these instructions below.
PEG3350
Give ______grams _____ a day for _____ days.
Pico Salax
- In the morning, have your child drink ____ sachet(s) diluted with 150 mL (5 oz) of water.
- ____ hours later, have your child drink _____ sachet(s) diluted with 150 mL of water.
Maintenance phase
Once the bowels are empty, you need to continue the medicine prescribed by your child's health-care provider.
PEG3350
Give ____ grams ____ a day.
Continue maintenance for at least ______ month(s).
When can my child stop taking their medications?
Do not consider stopping medications until your child has been doing well for at least six to 12 months. Do not change your child's medication dose before speaking with your child’s health-care provider. Your child's health-care provider will reduce their medication dose slowly, usually by a quarter dose every three to six months. Slow tapering is necessary to ensure that good toileting, dietary, fluid intake habits can be established, and the bowels can shrink back down to normal size.
Points to note
Medications
- Medications for constipation are safe as long as your child’s health-care provider monitors your child. They will not make your child's bowel "lazy".
- Follow your health-care provider’s advice and remember that labels on the products are for general use, not for each person's individual needs.
- Most children need the adult dose or even a higher dose of the medication for them to be able to pass stool properly.
Constipation
- You have the best chance of treating constipation by having your child empty their bowel at least once a day without rushing.
- It is common for children to experience constipation again, even after successful treatment. Some children might have difficulty with passing stool into their teen years or as adults.
Soiling
- Soiling is accidental. It is not a sign that your child is deliberately being bad.
- Soiling may get worse when treatment starts and can last for 12 to 24 months.
Follow-up
You will only treat soiling successfully if you continue to follow up regularly with your child's health-care provider. For example, speak to your child's health-care provider if you feel your child's treatment needs to be changed.
Does my child need to follow a special diet as part of their treatment?
Your child does not need to follow a special diet as part of their treatment, but they should eat a balanced diet including whole grains, vegetables and fruit. This will give your child the fibre they need to help with passing stool. You should also make sure that your child drinks plenty of fluids.
How can I stop my child withholding stool in the future?
- Encourage "toilet time" three times a day for three to five minutes
- Toilet time is often most successful within 20-30 minutes after a meal so schedule these following breakfast, lunch and dinner.
- Depending on your child's age, make toilet time as comfortable as possible by having good foot support (e.g. foot stool) available while your child sits.
- You can help your child “bear down” (push) while trying to pass a stool by having them blow on a pinwheel or blow up a balloon.
- Do not give your child distractions during toilet time such as toys or tablets. Instead, during this time they should be encouraged to focus on actively bearing down. Younger children who may not understand the instruction to push while on the toilet can blow up balloons, blow bubbles or blow on a pinwheel to help them bear down.
- Keep a record of how often your child passes stool.
- Do not punish your child if they do not pass stool during toilet time. Instead, set up a reward system for your child when they practice desired behaviours like sitting on the toilet for the entire toilet time, taking medications, drinking fluids and helping to clean their buttocks or diapers. The aim is to reinforce good behaviour and ignore soiling.
- Maintain a consistent, positive and supportive attitude right through your child's treatment.
Virtual care services for children
Boomerang Health was opened by SickKids to provide communities in Ontario with greater access to community-based services for children and adolescents. For more information on virtual care services in Ontario to support bladder and bowel dysfunction, visit Boomerang Health powered by SickKids.
Sources
NASPGHN (2006). Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for pediatric gastroenterology, hepatology and nutrition. Journal of Pediatric Gastroenterology and Nutrition, 43: e1-13.
Margolis, I. (2010). Treatment of Chronic Constipation and Encopresis.
Rowan-Legg, A. (2011). Managing functional constipation in children. Paediatric Child Health, 16(10):661-665.
Lane, M., Czyzewski, D., Chumpitazi, B., Shulman, R. (2011). Reliability and validity of a modified Bristol Stool Form Scale for children. Journal of Pediatrics, 159:437-441.