When to worry about constipation in children, and what to do about it

Photo by Nathan Dumlao on Unsplash
Photo by Nathan Dumlao on Unsplash

Poo. Stool. Number two.

Whatever you call it, it’s a subject that probably comes up often as you chat with other new parents, but less and less frequently as your children grow and settle into their bodies.

Yet, for parents whose children suffer from severe constipation or its related condition, encopresis (soiling), bowel movements occupy a central, at times obsessive, position in their lives.

How do I know this?

Well, because my 4-year-old son suffered from severe constipation and encopresis for more than two years before we finally found the help we needed to put him on track to normal bowel movements.

If you’ve sailed through toilet training, it’s hard to understand the heartache of parenting a child who goes so long without pooing that his lower colon begins leaking.

It’s nearly impossible to hold back the tears when you are changing yet another pair of undies, or soothing your child because someone said he smells.

Also read: How stress affects your children, and how to recognise the signs

I'm not on my own here.

Brigitte’s 6-year-old son Jamie suffered constipation for two and a half years.

She says, “We felt very alone. There is a stigma around constipation, and it’s not something that you can easily share with other parents, like other health issues."

"But I have found that so many parents are going through the same anguish that it’s important to speak out about it.”

Stephanie whose son, Thomas suffered from acute encopresis when he started Grade R, agrees, “I don’t think there was anything on the internet that I have not read about the condition. I was desperate to talk about it but could not find anyone to talk to.”

Getting professional help

Johannesburg paediatric gastroenterologist Dr. Michele Zuckerman says that in practices like hers, children suffering from severe constipation and encopresis make up around 10 to 25% of patients.

“Worldwide studies have shown that about 10% of children suffer from constipation of varying degrees, from mild to severe and including soiling.”

Studies have also shown that encopresis occurs equally in younger boys and girls, but by school age, it is much more common in boys.

It leads to irritability, a decrease in appetite, sleep disruption, mood swings, and discomfort.

How to approach the issue

The best approach to the problem, says Zuckerman, is holistic and multi-disciplinary.

“You need a medical professional with a very specific interest in it – it doesn’t have to be a paediatric gastroenterologist and could be a general paediatrician with a specific interest in managing constipation.” 

“The specific interest is important because the input that you need is intense. You can’t see a kid with constipation once a month or once every three months and hope to win.”

A play therapist or a behaviour therapist might also get involved, but the main input that is needed is from the parents. They play the key role in overcoming the problem.

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The starting point is to understand the condition, says Zuckerman, “constipation in the majority of cases is not due to a disease or an organic medical condition. It is what we call functional constipation, or functional faecal retention.”

What causes it?

The child’s history reveals an infrequent passage of stools that are hard and associated with pain. A dynamic starts when a painful stool is passed, and the child then starts retaining.

Over time, a mass of hard stool occupies the lower colon, weakening the muscles there and affecting the nerves that signal that it is time for a bowel movement.

Eventually, the lower part of the colon becomes so full that softer poo may leak out around the large mass of faeces, soiling the child’s underwear.

The child is not being naughty, the soiling is completely involuntary.

Stephanie says she looks back with horror and guilt, “I used to scream at my son or would show him how disappointed I was when he soiled. I now know he had no control over it.”

Zuckerman says it’s often triggered during weaning or toilet-training.

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“When babies are being weaned, their fluid intake decreases and solid foods are introduced. The result can be hard stools. The other time is toilet-training, either too premature, or too much emphasis, total confusion, or fear of the toilet. Acute illnesses can also bring it on.”

It was during weaning that Jamie’s problems set-in, says Brigitte.

For years they sought help from complementary healthcare practitioners, including reflexology and homeopathy.

Finally, he nearly collapsed from severe stomach pain and was admitted to hospital.

“The paediatric surgeon had to clean him out under local anaesthetic. The stool was almost as hard as cement and he had the anal capacity of an adult.

We followed that up with twice enemas daily, combined with behaviour modification through star charts and loads of encouragement from the entire family.

Nine months later he began to pass normal stools on his own and we have never looked back. My only regret is that I didn’t seek professional help earlier.”

In Stephanie’s case, her son’s encopresis appears to be linked to Attention Deficit Disorder.

“Play therapy helped enormously because the psychologist was able to determine an associated ADD and put him on Ritalin. It was a turning point for all of us and the encopresis has virtually stopped.”

Stephanie also altered her son’s diet using stool softeners and increased fibre.

Different solutions 

Each case is different and needs specific solutions.

For my son, a combination of stool softeners and a short-term stimulant, combined with intensive care from our medical professional and our family, as well as behavioural modification techniques, has put him on the road to normality.

The result is a boy who now sleeps through the night, who is confident about going to the toilet, who has more energy and appetite and who can now go on playdates with ease.

In short, a changed child.

Dealing with the problem

The sooner you react to constipation and treat it, the better, but Zuckerman warns against becoming too obsessed. “Many children respond themselves. After one hard bowel movement they start eating and drinking correctly and it comes right.”

“The severe kids, where they are soiling and going without a stool for three or four days or only going once a week, need specialised care.”

Adequate fibre and liquid intake are essential in preventing constipation, but studies have shown that simply increasing your child’s fibre and liquid intake won’t shift a hard mass of stool.

Complete bowel evacuation is the first step, through enemas, or orally with stool softeners like Duphalac (which can be used long-term). If this doesn’t work, a short-term stimulant (laxative) can be used under a doctor’s supervision.

These are combined with behaviour modification methods, such as a star chart (a star for each time he doesn’t soil, for each bowel movement, for sitting on the toilet, for eating and drinking well).

A play therapist is recommended if you are not winning on your own and the child continues to refuse to sit on the toilet.

*Note: Author's name redacted to protect her child.

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