More than a few days have passed and still nothing has happened. The young patient refuses to pass stool or “poop” as parents say. Day by day they become increasingly anxious. The child’s desperate cries fill the air. After many hours of listening to their child’s agonizing screams, finally a big chunk of concrete-hard stool mixed with streaks of blood appears. The mom is in tears and her husband calls the doctor: it is 3 a.m. It is my impression that this common problem, constipation, plays itself out more and more often in many homes across Canada.
What causes it? What can be done to treat it safely and, more importantly, what can parents do to prevent it from happening in the first place? Lack of correct diet plays a major role – insufficient amounts of fluids, fibre and fruits are to blame. Combine this with a more refined North American diet, a picky eater and a toddler who is too busy watching TV and we have the sure recipe for trouble: pain, tears, blood in the stools and nothing but frustration that may last weeks, and maybe months in rare cases. This is what happens in the child who stools normally: First, the rectum (the storehouse in the gut, prior to getting to the anus) is filled with stool/fecies. The message goes up to the brain...”let me go”. The child chooses to stool and all is well. However, for the constipation-prone child, there are two choices: to go or to delay. Unlike the filled bladder, the filled rectum when denied the chance to empty says, “I can handle this. What I’ll do is stretch and stretch a bit more, till next time.” The problem is that with each “next time” the situation just gets worse and worse. Soon, the whole sensation is damaged and the rectum becomes very stretched – stretched to the point where it can accommodate a toddler’s stool big enough to block the toilet! (Plumbers are called in.) Some loose stool higher up the bowel leaks through and stains the underwear. The patient becomes embarrassed and may decide to even hide the stool in the most unusual places. The child starts to smell and gets ridiculed and rejected. This becomes a big problem that is, no pun intended, hard to solve.
Solving it involves a visit to the doctor first of all. Although the vast majority of patients by far have no structural problem accounting for constipation, it needs to be ruled out. A complete history and thorough exam usually achieves the latter goal. Sometimes an abdominal X ray may contribute something, such as telling the doctor just how far stool is backed up along the bowel (much like a helicopter looking down over Deerfoot Trail, seeing how far cars backs up after traffic is blocked off by an accident.) Treating constipation, involves what I call “the two-step-approach” – empty the rectum of fecies and keep the stools soft. A suppository in the very young or an enema in the older child achieves the first goal. Be prepared for much discomfort. After all, the problem did not occur overnight and, like obesity, it takes much time, patience and consistent efforts, despite the patient’s protests. Once the rectum is empty, it does not return to its original size like a balloon that is deflated. Instead, just like a pregnant uterus, once the baby is born, it takes time for things to return to a smaller size. This is the time when the stools have to be kept soft. Soft stools are achieved by what I call “the-three-F-approach:” fluids, fibre and fruits. I am always keen to try this before medication is attempted but sometimes the problem so big that one has to use both diet and medication. Once momentum is achieved, the medication can be left on the shelves, as long as the dietary efforts remain the main focus.
A diet high in fat slows down bowel movements. One should, at least in the child over two years of age, cut back from a high fat diet. For example, homogenized milk in the older child can be replaced with lower fat milk. As far as milk goes, a recent article in the American Academy of Pediatrics’ publication (“Pediatrics”), reminded clinicians that constipation – not diarrhea – may be one way for a milk intolerance to manifest. I am not ready to support the late Dr. Benjamin Spock’s enthusiasm that milk is the root of all evil, but keep in mind milk as a possible suspect in this particular “crime.”
What if the child refuses to eat more fruits and fibre? I do what most paediatricians do at this point – ask for help! Help comes from my esteemed dietician colleagues: they have many “tricks” in their bags and often are very specific about which other foods may be helpful. Putting fruits and fibre in a blender may help. It is true; we so often are what we eat. Constipation illustrates this only too well. One last note: make the time, consciously, to eat with your child. Do it without being in a hurry and be sure to switch off a very common interruption – the television.
Access www.healthykids.ca for a terrific new resource in helping families raise healthy children - HealthyKids with Dr. Nieman will optimize your child's complete health.
An informed parent is ... an empowered parent.