Part 2: Conquering constipation:
Dealing with constipation in older children
Constipation in older children is different to that in babies for a number of reasons. Older children have developed certain eating habits, may be experiencing different levels of stress and anxiety and have sometimes developed negative associations with passing a stool. These factors play a significant role in the diagnosis and treatment of constipation.
Again it is important for a practitioner to know what the child’s stool looks like. Generally children from about the age of five years are able to identify what their poo looks like from the picture presented to them. After the giggles a doctor can get a pretty good idea of the stool’s appearance and be in a better position to give advice on an action plan.
Below is a chart known as “The Bristol Stool Form Scale (for children)”. It shows in picture form what stools may look like. Although children aren’t always able to accurately describe their stool an adult who cares for them often can. The sausage or chicken nugget stools are what we want to achieve. They are easy to pass and the child experiences no discomfort.
Symptoms that your child is constipated
- Many days without a bowel movement. This may be an obvious sign but it is important for parents to be aware if their children are actually going to the toilet.
- Abdominal pain, poor appetite and nausea. I often have children presenting in my office with severe tummy pain. Parents report that the child has been passing stools. It may be that the stool is impacted high up in the intestine and what the parents see as stool is actually overflow diarrhoea. An x-ray of the tummy often reveals faecal loading in these children ( a severe backlog of stool)
- Strange movements. Parents have reported their children making strange movements and assume that they are in pain. A child may pull faces, stretch, clench their bottom, or cross their legs. This is often in an attempt to avoid having to go to the toilet and this kind of avoidance will also lead to constipation.
- Soiling of underwear. Another name for this is encopresis. If a child withholds stools then the stools build up and a large stool is produced that can stretch the rectum. When this happens the child may no longer experience the urge to pass a stool. Hard stool collects at the bottom of the colon. The soft, loose stool higher up in the intestine leaks past the hard stool and out of the anus. Initially it may present as smudges in the underwear and be attributed to poor cleaning. As time goes on however the child may pass the entire stool into their underwear without having any control over the movement. Such cases of constipation require medical intervention.
Diet is usually blamed for constipation in children older than a year. Diet certainly plays an enormous role and I will spend some time going through the kinds of food one needs to ensure is part of your child’s diet. There are other significant causes of constipation and these include:
- Stress/ Anxiety
- Lack of exercise
- Painful passing of stool
- New environments
It is really important that parents assess the root cause or causes of your child’s constipation. It may be that you look at each of these areas and determine if one or more of these factors are causing the problem.
- Stress and anxiety: In my experience children these days often experience a longer day than the majority of adults. They get up early for school and are often hurried through breakfast to get through the traffic and be at school on time. After school they are rushed from one sports activity to another or have to attend extra lessons because they are struggling with school work. All of this stress causes the child to go into “flight or fight mode” where the muscles tense up. This includes the anal sphincter muscle. There is no way a child will pass a stool in a state of anxiety. It is just not physiologically possible.
What can be done?
It is extremely important for parents to ensure that a child has a time when they just sit on the toilet. It doesn’t matter how long it takes and should form part of a healthy routine. It sounds crazy but there are times when a parent needs to schedule this into the program if your child is ever going to be able to have a normal bowel movement. It is recommended that a child suffering from constipation spends 10 minutes after breakfast and 10 minutes after dinner on the toilet.
I would also advise an Epsom salts bath. Not only will your child relax in the warm water but the minerals in the salts relax muscles and provide magnesium, a much needed element in the treatment of constipation. ( more about magnesium under diet)
- Lack of exercise: The latest buzz word in the parenting world is “limiting screen time”. Absolutely! If a child doesn’t move then the intestine can’t move. Children need to be running, jumping, swimming and having physical fun and in turn these activities will get the child to relax and the muscles of the whole body to begin working. A healthy stool won’t be far behind.
- Painful passing of stools: Pain may be experience is the stool is particularly large or hard. When a child is constipated they may avoid making a stool for fear of pain. The approaches taught here are important to get past painful stool.
- Travel and new environments: It is not uncommon to become constipated when on school camp. The tendency to avoid passing a stool when away from home and surrounded by others may result in constipation. Ensuring your child return to their normal routine as soon as possible is essential.
- Withholding: Between the ages of 2 and 5 years a child may be dealing with issues of independence and control. This can lead a child to become constipated. Sometimes a child simply gets too caught up in play that they ignore the urge to go to the toilet. If this occurs regularly then they become constipated and the difficulty around passing a hard stool presents itself.
What to do about withholding- Routine is really key here so that the child has time to sit on the toilet and not be distracted by toys or other children. If the withholding occurs during potty training time then it is important that a fuss is not made about the process but instead the child should be encouraged and praised when there is success.
- Diet: I cannot stress the importance of diet enough when dealing with constipation.
Parents have been told about fibre and water over and over again when their child is constipated. To this I would like to stress the importance of including magnesium rich foods as well. Perhaps these guidelines will assist in making the changes.
- Water- It is generally accepted that a child who is five years old and weighs about 18kg should be drinking about 500mls of water a day (two glasses). If you are the kind of parent who likes formulas then work on about 30ml of water per kg of weight. What I like to advise my patients is that their wee should be light yellow in colour. That way they will know they are well hydrated.
- Fibre- There is a general guideline for the amount of fibre that children need in their diets:
This kind of guide may seem confusing at first but perhaps the tables below will give a better idea of how the fibre can be included in the diet. http://www.tune1st.com/photo/gal_308/fib1.jpg
- Foods rich in magnesium: The modern diet often means that our bodies are deficient of magnesium. You guessed it! One of the symptoms of low magnesium is constipation. The good news is that the foods rich in magnesium also provide fibre and your child certainly doesn’t have to eat huge quantities to get a good dose of this wonder mineral.
Some of the foods you can give your child that are rich in magnesium include:
|Food||Serving size||Magnesium (mg)|
|Dark leafy greens||1 cup cooked||157mg|
|Nuts and seeds (esp pumpkin)||30gm||150mg|
|Squash (esp gemsquash,butternut)||1 cup||43.20mg|
|Green beans||1 cup||22.50|
|Dried Beans and lentils (esp soybeans)||1 cup cooked||148mg|
|Quinoa||¾ cup cooked||118mg|
|Brown rice||1 cup cooked||84mg|
|Dried figs||1/2 cup||51mg|
I truly hope that at this point you will be getting an idea of what to include in your child’s meals. I imagine their school lunchbox will be a picture of colour with added treats like cucumber sticks and strawberries. After all we all enjoy something new and fresh on our plates. Your child’s overall health will be improved and the stress around the constipation issue reduced.
The ability to pass a normal stool in today’s world is in itself an accomplishment. Children are bombarded with unrealistic demands, highly refined foods, fast foods and a host of distractions. Constipation accounts for the major reason children are referred to gastroenterologists. It is within our reach as parents to impact the lives of our children so that they are able to pass normal stools and get on with the business of being children. There are times when an illness causes constipation and medical intervention is vital. Other times it is circumstances and poor diet that leads our children down a road of continual tummy problems. It is a difficult condition to manage but it is not an impossible one. Take heart, diet, relaxation, exercise and a positive attitude to bodily function goes a long way to relieving constipation.