Normal bowel patterns are very variable in children of all age groups. When there is delay in defaecation with difficulty or distress, the child is said to suffer from constipation. Constipation has also been defined as passing less than 3 stools per week.

Constipation is a common problem. It is said to account for 3% of all visits to a paediatric practice and 25% to a paediatric gastroenterology clinic.

Many children presenting with constipation are said to show stool-withholding manoeuvres e.g. crossing their legs or sitting up on their heels.

Serious organic causes are rare and account for < 10% of constipation in children.

Generally, constipation starts after a specific identifiable trigger. A viral infection may result in decreased intake of liquids. Stools become solid causing the child to strain and passage of hard faeces may result in an anal fissure. Defaecation becomes painful which starts a negative cycle, leading to retention of stools. Other common triggers are unavailability of toilet on holiday/camping, school restrictions, teasing by classmates, avoidance of toilets at school or home.

In infants, cow’s milk allergy may be a contributing factor. In infants, removal of dairy can help but in older children this is less likely to help.

Hirschsprung’s disease is a serious condition where the nerves to bowel are not present. It is a congenital condition present from birth. It is rare but should be considered in any child with chronic constipation. However, it has been shown that if the age at onset of constipation is after the neonatal period, Hirschsprung’s is an extremely unlikely diagnosis.

Treatment may involve education and behaviour therapy, diet advice and laxatives. The approach depends on the age of the child, duration of symptoms and severity.

Laxatives can be divided into four groups based on their mechanism of action.

  1. Bulk forming laxatives, which increase faecal mass and stimulate peristalsis
  2. Stimulant laxatives, which increase intestinal motility
  3. Faecal softeners (Liquid Paraffin) whose action is mainly to lubricate and soften the stool probably by lining colonic pits and preventing colonic water re-absorption.
  4. Osmotic laxatives which keep fluids in the bowel by osmosis or by changing the pattern of water distribution in the faeces.

The key to successful treatment is proper evacuation with appropriate maintenance therapy. The medication doses have to be increased or decreased according to each individual’s requirement. It is important that the doses should not fluctuate too often. The dose change should be planned and gradual.

How long will I need to treat this for? Unfortunately there is no single answer. Common practice is to aim for one bowel movement per day on constant dosage. Subsequently after a period of months rather than weeks gradual decrease in dosage of laxatives may be initiated in very small steps. We use an arbitrary figure of 3-6months. Consistency of treatment is key to getting of treatment! One needs to be aware that reducing treatment may be accompanied by re-emergence of symptoms.