Constipation Problem in Babies and Children

Constipation is the condition of children having two or less painful, hard stools per week. Constipation is present in 3% of children admitted to the pediatric outpatient clinic. 95% of constipation in children is functional constipation and there is no underlying disease. In the remaining 5%, constipation can be caused by surgery or other diseases.

What conditions are considered constipation?

At least two of the following symptoms are younger than 4 years old Constipation is considered as constipation if it persists for one month in children and two months in children older than 4 years:

• Two or less defecations per week

• Painful or hard defecation

• History of defecation

• Too much defecation at once

• At least once a week incontinence with soiling of underwear

• The last part of the large intestine (rectum) is always full

How is the normal functioning of the intestines?

• Babies are dark within 24 – 48 hours after birth They make their first colored stool (meconium)

• Afterwards, breastfed babies have golden yellow stools on average 4 times a day. This number may be less in those who are fed with formula

• When children reach the age of 2, this number decreases to two per day on average

• Defecation of children who are 4 years old their patterns begin to resemble those of adults: they can range from 1 – 2 times a day to every 2 – 3 days

How does constipation develop?

As stated, 95% of constipation in children is functions and there is no underlying anatomical problem. Mostly, dietary changes or stress situations that children are exposed to cause functional constipation. These reasons can be summarized as follows:

• Transition from breast milk to formula

• Conversion to supplementary food

• Toilet training (especially challenging toilet training)

• Starting daycare or school

• The child's daily schedule is very busy (school and additional lessons during the day)

• Stressful situations at home

• Illness, dehydration

   A child who is constipated once and has hard stools causes pain due to excessive stretching during defecation. Afterwards, the child, who is afraid that defecation will be painful, tries to avoid pain by holding his stool this time. At this time, the liquid part of the stool in the rectum is absorbed and the stool begins to harden more and more. When the child reaches the level that he can no longer hold his stool, he begins to feel more pain and discomfort, and a vicious cycle begins. Over time, it can cause anal fissure (painful tears in the skin at the buttock exit), rectal prolapse (the last part of the large intestine protrudes from the buttock) and hemorrhoids (hemorrhoids). causes enlargement of the last part of the large intestine. At this time, the more runny stool from the top leaks around the hard stool, causing the child to soak (soiling) his underwear.

How to diagnose constipation?

  Detailed history and physical examination are sufficient for the diagnosis of constipation. The family should be asked predetermined necessary questions and not even the smallest detail should be skipped. In the physical examination, abdominal and anal region examination is performed. Whether additional tests and tests are needed is decided as a result of these examinations and during follow-up if treatment has been started.

Which types of constipation are there?

• Idiopathic constipation (developing in infancy, of unknown cause)

• Breastmilk constipation ('false constipation')

• Constipation of formula formula (in babies who switch from breast milk to formula feeding)

• Constipation of rice, cereals (in those with rice flour added to their diet from 4 to 5 months of age)

• Infantile dyschesia ('straining' before passing stool in infants up to 6 months of age)

• Constipation of whole milk (high protein carbohydrate ratio)

• Psychosocial constipation (for those new to toilet training)

• Functional constipation (seen in 95%, 'vicious circle')

• Constipation due to underlying anatomical causes (some surgical and non-surgical diseases)

Is the stool frequency and shape of babies always a sign of constipation?

  As stated, babies defecate an average of 4 times a day. This number may increase or decrease depending on the type of nutrition (breast milk, formula) and amount.

   But in some cases, only breastfed babies cannot defecate daily, and this period may extend up to 1 week. They do not experience discomfort when defecating and their stools are soft. This is normal in babies who are fed normally, have good development, do not have restlessness, vomiting, and have no bloating, and this is not considered as constipation. It is also known as 'false constipation' among the people and there is no need for intervention. Mostly, they start defecating daily during the transition period to supplementary food.

 Sometimes, babies younger than 6 months, who have no additional problems, whose development and nutrition are normal, strain a few times a day before they defecate, pull their feet to themselves, and defecate as if forcibly. Stools are soft. This condition is also not considered as constipation. These babies are not constipated, but their defecation mechanisms are not yet fully developed. In the normal process, contraction of the abdominal muscles and synchronous relaxation of the last part of the large intestine are required for defecation. In this condition, which is considered to be 'infant dysgesia', babies actually contract their abdominal muscles to defecate. This condition is temporary and returns to normal within a few weeks. In particular, interventions such as rectal stimulation should not be made.

Treatment of constipation in children

  Constipation in children is difficult to treat and long-term, requiring cooperation of children, families and doctors, and should not be underestimated It is a necessary disease. It is mostly seen without other underlying diseases. Constipation should be handled with all its aspects and efforts should be made to solve all of the problems that cause it. several stages I treatment can be summarized as follows:

• Hard stool, if any, should be emptied (with oral medication or enema)

• The child's regular soft stools Medication should be arranged for the patient to do it (medicines with different mechanisms of action depending on the child's age and constipation)

• Acquiring a proper toilet habit (sitting on the toilet after every meal, putting a stool under the feet, knees less than the hips) high, not to force, not to rush, not to procrastinate at playtime or school)

• Treating conditions such as anal fissures

• Regulation of the child's diet

  • Consumption of plenty of fluids

  • Nutrition with foods rich in fiber

• Family education

• Psychological counseling if necessary (family-child integrity, supportive attitude of the family, not blaming is important)

• Investigating other underlying diseases in suspicious cases (anatomical cause)

Constipation is difficult to treat and requires patience. Medications started may not have an immediate effect, and long-term use, occasional dose adjustment and re-adjustment of therapy may be required. It may even take a long time for children to overcome the difficult and painful defecation habit that they are used to.

   Everything can go back to normal when parents stop the treatment early when they think that they have benefited by their own decisions. Treatment should be continued for at least 2-3 months and the child should have regular, soft stools for at least one month.

Does constipation recur?

Constipation may never go away if the treatment is stopped early and not done as recommended. or it may recur in a short time. About 25% of people who are constipated in childhood may also have constipation in adulthood.

Which additional diseases can cause constipation?

5% of constipation is caused by anatomical reasons. Among these, Hirschsprung's disease, anal atresia, and anal stenosis, which need to be surgically corrected, are more common. While k is seen, hypothyroidism, hypokalemia and hypercalcemia, Celiac disease can be seen most frequently among other group diseases. When these conditions are suspected, the diagnosis can be confirmed with appropriate additional tests.

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