Constipation in Children & Newborn

Overview of Constipation in Children and New Born

It is increasingly being recognized as a very common problem in children and is associated with both physical and psychological morbidity and a poor quality of life.

The normal stool frequency decreases from 4 or more per day during infancy to once per day at 4 years of age. A stool frequency of <2/week is considered abnormal for all ages. Constipation can be divided into two groups:

1. Firstly, functional
2. Secondly, organic.

The organic in a study of 135 Indian children with constipation, 85% had functional constipation and 15% had an organic etiology (most commonly, Hirschsprung disease, cerebral palsy and meningomyelocele).

Indian epidemiology then other

Causes of Constipation in Children and New Born

Functional Constipation

The increase in intake of low residue diet and sedentary lifestyle is responsible for the increase in functional constipation in children.

Functional constipation is defined by the presence of at least 2 or more of the following criteria:

1. Two or fewer defecations in the toilet per week
2. At least 1 episode of fecal incontinence per week
3. History of retentive posturing or excessive volitional stool retention
4. History of painful or hard bowel movements
5. Presence of a large fecal mass in the rectum
6. History of passage of large diameter stools that may obstruct the toilet.

• Generally, Children with functional constipation pass large or hard stools and display stool withholding behavior, characterized by stiffening of whole body and screaming in infants, to walking on tiptoes or tightening of buttocks in older children. Additionally, This is often misunderstood by parents as if the child is trying to defecate.
• Moreover, Often an acute illness, change in diet, coercive toilet training or nonavailability of clean toilet leads to non-passage of stools. Besides this, The stools become hard and cause pain on passage which leads to association of defecation with pain and withholding.
• Lastly, These further increases stool size and hardness with more pain on defecation and a vicious cycle of constipation is initiated. Children with functional constipation often have abdominal pain (10-70%), anorexia (10-25%), enuresis or urinary tract infections (30%) also psychological problems (20%).

Organic Cause of Constipation

Intestinal nerve/muscle disorders e.g.:

• Hirschsprung disease
• Intestinal neuronal dysplasia
• Pseudo-obstruction

Spinal cord abnormalities e.g.

• Tethered cord
• Myelomeningocele

Anorectal e.g.

• Anteriorly placed anus
• Anal stenosis
• Rectal stricture
• Pelvic mass (in other words, sacral teratoma)

Systemic disease i.e.

• Hypothyroidism
• Celiac disease
• Diabetes insipidus
• Diabetes mellitus
• Hypercalcemia
• Cystic fibrosis
• Myotonic dystrophy

Developmental i.e.

• Mental retardation
• Autism

Drugs i.e.

• Opiates
• Anticholinergic agents
• Phenobarbitone
• Vincristine
• Lead

Types of Constipation in Children and New Born

Depending upon cause i.e.

1. Firstly, Functional Constipation
2. Secondly, Organic Constipation

Risk factor of Constipation in Children & New Born

• Low fiber diet.
• Psychological stress
• Cow’s milk protein allergy
• Familial predisposition
• Prematurity
• Living in urban areas.(1)

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Pathophysiology of Constipation in Children & Newborn

The Pathophysiology of functional capacity in children remains unclear but is multifactorial. 3 most commonly discussed theories are

1. Withholding behavior
2. Slow transit
3. Genetic factors.

The most common mechanism for developing FC,especially in younger age group, is withholding behavior.

1. Withholding behavior

• The psychology of functional constipation can be explained based on three events.

1. Initial events.
2. Cycles of fecal stasis
3. Stool-withholding maneuver

• Events/causes that lead to initial painful defecation and later develop as functional constipation.
• Change in routine loke the timing of defecation or diet, starting of school.
• Stressful events like physical or sexual abuse
• Inter-current illness.
• Non availability of toilets such as long and frequent travels.
• Chil’s postponing defecation because he or she is too busy.
• Forceful toilet training.

All these events give rise to large, hard stool and the passage of such stools leads to stretching of the pain sensitive anal canal. As a results of this child decides to avoid defecation.

2. Cycle of fecal statis

• Withholding of feces leads to prolonged fecal stasis in the rectum, with the resultant absorption of fluids and harder stools.
• Successive retention of stools in the rectum makes them larger.
• As the cycle is repeated, successively greater amounts of larger and harder stools are built up in the rectum and passed with even greater pain accompanied by sever " stool withholding maneuvers".

3. Genetic factors

• Many children with functional constipation have a positive family history.
• In this subgroup genetic factors may play a role.
• Neurodevelopmental disorders such as autism spectrum disorders can be associated with functional constipation resulting from lack of adequate behavioral response to a defecation sensation.(2)

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Sign & Symptoms of Constipation in Children & Newborn

Symptoms of constipation in children may include your child

• Having fewer than two bowel movements a week
• Passing stools that are hard, dry, or lumpy
• Having stools that are difficult or painful to pass
• Telling you that he or she feels that not all stool has passed
• Changing positions to avoid or delay having a bowel movement, including
  • standing on tiptoes and then rocking back on his or her heels
  • clenching his or her buttocks
  • doing unusual, dancelike movements
• Having a swollen abdomen, or bloating
• Having daytime or nighttime wetting
• Having stool in his or her underwear that looks like diarrhea

If your child avoids or delays having a bowel movement, he or she may develop a fecal impaction. (3)

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Diagnosis of Constipation in Children and New Born

• Approach a detailed history and physical examination is the most useful tool for making a diagnosis of constipation. The details about pattern of stooling, time of first passage of meconium, presence of blood in stools, diet, stressful life events, drug intake and previous surgeries should be known.
• A predominantly liquid and low fiber diet (milk based) is common and contributes to constipation. A complete physical and neurological examination is essential. Examination for features of spina bifida (pigmentation or tuft of hair on lower back), power in lower limbs, perianal sensation, voluntary contraction and tone of anal sphincter and amount and consistency of stool in rectum on per rectal examination are extremely useful for diagnosis.
• Presence of ‘red flags’ like failure to thrive, blood in stools, recurrent fever with loose stools (enterocohhs), recurrent vomiting, lump in abdomen, recurrent chest infections and features of hypothyroidism should alert the physician to suspect organic etiology.
• No investigations are required for diagnosis in the majority of children with functional constipation. However, an X-ray abdomen may be done to document impaction in select situations, e.g. an obese child who is not willing for a per rectal examination.

Differential diagnosis of Constipation in Children & Newborn

• Anorectal anomaly
• Hirschsprung disease
• Group A streptococcal perianal skin infection
• Anal fissure
• Lichen sclerosis et atrophicus
• Anal sexual abuse
• Myotonic dystrophy
• Crohn disease
• Gluten enteropathy
• Hypothyroidism
• Neurofibromatosis
• Genetic diseases (6)

Complications are what happen after you have a disease. They are the negative consequences of the disease process.

Investigation of Constipation in Children & Newborn

• Abdominal X-ray. This standard X-ray test allows your child’s doctor to see if there are any blockages in your child’s abdomen.
• Anorectal manometry or motility test. In this test, a thin tube called a catheter is placed in the rectum to measure the coordination of the muscles your child uses to pass stool.
• Barium enema X-ray. In this test, the lining of the bowel is coated with a contrast dye (barium) so that the rectum, colon and sometimes part of the small intestine can be clearly seen on an X-ray.
• Rectal biopsy. In this test, a small sample of tissue is taken from the lining of the rectum to see if nerve cells are normal.
• Transit study or marker study. In this test, your child will swallow a capsule containing markers that show up on X-rays taken over several days. Your child’s doctor will analyze the way the markers move through your child’s digestive tract. (4)
• Blood tests. Occasionally, blood tests are performed, such as a thyroid panel.

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Treatment                                                     

• In detail, Two main steps in the management are disimpaction and maintenance therapy.
• Disimpaction require in patients who have a rectal impaction, i.e. presence of a large hard mass of feces on per rectal examination. Rectal impaction is responsible for progressive dilatation of the rectum over time also increased threshold volume for rectal sensation and defecation.
• This ‘clean out’ is essential if maintenance therapy is to be effective.
• The oral route prefer over rectal as it is less invasive. Additionally, total bowel wash is done to clean the entire colon using polyethylene glycol (in other words, PEG) in a dose of 1.5 g/kg/ day for 3-4 days at home. Alternatively, PEG electrolyte solution can give in the dose of 15-40 ml/kg/hr till the rectal output is clear and devoid of solid fecal material. In young children, this should done using a nasogastric tube and in hospital under supervision. The child should fast for PEG administration.
• Intravenous fluids may require in small children during this period to maintain adequate hydration.
• An alternative to oral administration of PEG is the use of phosphate enema or sodium dioctyl sulfosuccinate enema, 30-60 ml/10 kg body weight to a maximum of 120 ml, once or twice daily for 1-2 days. Repeated rectal enemas should avoid in children. The aim of the maintenance phase is to promote regular stooling and prevent reimpaction.
• Success of this therapy define as passage of 1-2 soft stools per day and no soiling. It includes the following components:
• Behavioral training involves establishing a positive routine of sitting on toilet for passing stools after meals regularly (specifically, 2-3 times per day for 5-10 min) and documenting all stool passage. Embarrassment or punishment should avoid.

Dietary changes

• Dietary changes. Furthermore, A nutritious diet with fruit/vegetables and adequate fluids give. A short trial of milk and milk product free diet may done in cases suspected to have milk allergy.
• Regular and tailor-made (as per response) laxative use is the key to success and this should explain to the family. Osmotic laxatives like lactulose (1-3 ml/kg/day) and PEG (0.8-1.0 g/kg/ day) are the first line agents.
• Stimulant laxatives like Senna or Bisacodyl are to use only intermittently as a rescue therapy to avoid impaction. Prokinetics like cisapride are not recommend. In infants, mineral oil also stimulant laxatives should not use.
• Glycerin suppository prefer over enema for impaction in infants. Besides this, Premature withdrawal of medications is a very common cause of relapse.

Prevention of Constipation in Children & Newborn

• Increasing your fiber intake: Fiber-rich foods, such as fruits, vegetables and whole grains, all help improve gut function. If you have bowel sensitivity, you’ll want to avoid high-fructose fruits, such as apples, pears and watermelon, which can cause gas.
• Getting more exercise: Regular exercise can help keep stool moving through the colon.
• Drinking more water: Aim for eight glasses daily, and avoid caffeine, as it can be dehydrating.
• Go when you feel like it: When you feel the urge to go, don’t wait.(6)

Prognosis 

• Most of the children need maintenance therapy for 6-24 months. About 50-60% patients achieve success Diseases of Gastrointestinal System and Liver at 1 yr and 70-80% in the long-term.
• Nearly 50% patients will have a relapse after successful therapy. In nearly one-third patients, constipation persists even after puberty.

Homeopathic Treatment of Constipation in Children and Newborn

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis.

Which includes

• The medical history of the patient,
• Physical and mental constitution,
• Family history,
• Presenting symptoms,
• Underlying pathology,
• Possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions.

What Homoeopathic doctors do?

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. Now a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improve with homeopathic medicines.

Homeopathic Medicines 

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy, potency and repetition of dose by Homeopathic doctor.

So, here we describe homeopathic medicine only for reference and education purpose. Do not take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath).

Medicines:

Nux Vomica – For Ineffectual Urging and Scanty Stool

• Nux Vomica is one of the most effective medicines for constipation cases of insufficient stool with ineffectual urging.
• Child brought up too early on animal food or the nurse takes too much coffee.
• A person who needs prescribing Nux Vomica passes scanty stool, very frequently.
• The stool is unsatisfactory and insufficient.
• Even after passing stool many times a day, there is a never “got done” feeling.
• Abdomen pain may arise along with constipation.
• More importantly, it also effectively treats piles from constipation.

Bryonia Alba – For Dry, Hard, Stool in Lump Form

• For constipation with hard, dry stool that passes in lump form, Bryonia Alba is considered one of the best medicines for constipation.
• The stool is dry, as if burnt, and pass with much difficulty.
• Abdominal distension also note in some cases.
• Headache from constipation may also effectively treat with Bryonia Alba.
• Faeces hard, dry as if burnt and of a dark color, so large as to give great pain in passing; dry lips and mouth.

Alumina – For Constipation with No urge to Pass Stool for Days

• Alumina is another well-known name on the long list of medicines for constipation.
• A guiding feature for the use of Alumina is the absence of the urge to pass stool for days together.
• Inertia of rectum; long-standing cases which resisted other drugs; abuse of farinaceous food; child has to make great effort to pass even a soft stool.
• The person needing Alumina will go days without passing stool.
• The intestine action is extremely sluggish.
• The stool pass only when there is a large accumulation of fecal matter in the intestine.
• Another important symptom for using Alumina is excessive straining to pass stool even when the stool is soft.
• Alumina also one of the majorly indicate medicine for constipation in children, infants, bottle-fed babies and among elderly persons.

Lycopodium Clavatum – For Flatulence and Bloating

• Lycopodium Clavatum works wonders in cases where constipation attend with flatulence and a bloated abdomen.
• Lycopodium Clavatum is also the most helpful medicine for constipation in elderly people.
• It is very useful in irritable bowel syndrome as well.

Silicea – For Constipation where Stool Recedes after being Partially Expelled

• In some constipation cases, the stool known to recede after being partially expelled.
• In such cases, Silicea is the most useful medicine for constipation.
• The stool is soft, needs straining to pass out, but recedes back into the rectum after being partially expelled.
• There is constriction of anus. Exhaustion attends straining efforts to pass stool.
• Burning, smarting pain at the anus may also arise.
• Stools with difficulty force to the very verge of the anus, when they slip back again.
• Rectum inactive; spine weak.
• Child’s head and face perspire copiously directly upon its falling asleep.

Antimonium Crudum- For constipation alternating with diarrhea.

• Antimonium Crudum is an effective medicine for constipation which treats soreness of rectum, anal itching, and mucus piles.
• It is extremely useful for alternating constipation and diarrhea.

Podophyllum– Alternating constipation and diarrhea

• Gurgling in bowels, prolapse of the rectum with stool.
• Clay-coloured stool or greenish stool and highly offensive stool.
• Alternating constipation and diarrhea.
• Obstinate constipation following diarrhoea in artificially brought-up children.
• Rolling of head, with moaning during sleep; eyes half open.

Natrum Mur – For Constipation when Stool is passed on Alternate Days

• In cases where stool is passed on alternative days, Natrum Mur is to regular rise bowel movements.
• The attending features are constriction in the rectum, smarting, burning or tearing pain at the anus.

Opium– For Dry, Hard Stool in Ball Form

• Opium work well in cases of constipation where the stool is hard, dry and passed in ball-like form.
• In addition, Opium is also the medicine for constipation where the has been taking laxatives to pass stool for a long time.

Calcarea carb:

• Hard, undigested, chalky stools of a light color.
• Poorly developed bones.
• Dry scald head.

Chamomilla:

• Constipation during dentition.
• Excessive dryness of faeces.
• Crumbling during stool, from inactivity of anus.

Causticum:

• Timid children afraid to go to bed alone.
• Abdomen swollen.
• Hard; knotty stool, like sheep’s dung, with red face from straining; nocturnal enuresis.

Diet and Regiment 

• Fibre Rich Diet
• Avoid Fasting
• Drink more Liquid, Juice
• Exercise

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Reference

1. Causes and Risk Factors of Constipation in Children | Download Scientific Diagram (researchgate.net)
2. Pathophysiology of functional constipation in children – DNB Pediatrics
3. Symptoms & Causes of Constipation in Children | NIDDK (nih.gov)
4. Constipation in children – Diagnosis and treatment – Mayo Clinic
5. Constipation in children – Differential Diagnosis (epocrates.com)
6. Constipation: Causes and Prevention Tips | Johns Hopkins Medicine