6-year-old Myra was experiencing frequent abdominal pain, which got her parents worried. Speculating a scary diagnosis, the parents took her to the doctor. The pediatrician examined and said, “Sounds like constipation.” The parents were left shocked about their child’s diagnosis.
Constipation is a common problem in children of all ages and can occur due to multiple factors. The prevalence of childhood constipation can be as high as 29.6%, and most cases tend to occur during the age of toilet training, when children are two to three years old. However, it needs to be understood that the longer children suffer from constipation, the harder it can get to deal with it, both physiologically and behaviorally.
We spoke to Dr. Neelam Mohan, DNB, MNAMS, FPGH(UK), FIMSA, FACG (USA), FIAP & FRCPCH (UK), National Coordinator & Sc. Convener- IAP Diarrhea module, Director Department of Pediatric Gastroenterology, Hepatology & Liver Transplantation, Medanta – The Medicity Hospital, Sector – 38 Gurgaon (Haryana), President – CAPGAN (Commonwealth Association of Pediatric Gastroenterology & Nutrition) and Dr Srirupa Das, Medical Director, Abbott India to know more about childhood constipation and how it can be treated.
How common is the issue of constipation among children? Dr Neelam Mohan: Estimated prevalence of functional constipation is 3% worldwide. The prevalence of childhood constipation is increasing in India. In a recent survey from India, functional constipation constituted 30% of pediatric gastroenterology office practice, 4-5% of all referrals to pediatric gastroenterology tertiary care centers and 0.8-1% of all pediatric cases in medical colleges1.
What’s the age group that gets most affected? Dr Neelam Mohan: Amongst children, most cases of constipation occur between 2 and 4 years of age, around the same time as toilet training. The other peak occurs amongst adolescents, commonly due to faulty eating practices.
What are the common issues that lead to childhood constipation? Dr Srirupa Das: Understanding the triggers for constipation in children is important. Children who have difficulty in toilet training are more likely to be constipated. Inadequate evacuation as a result of rushed morning routines or quick use of the school toilets, holding stools or decreased fluid intake could also be some of the reasons for constipation.
Should parents monitor their child’s stool? Is there any frequency of stool that’s considered right? Dr Neelam Mohan: Yes, parents should certainly monitor their child’s stool regime. If the child is having difficulty passing regular bowel movements, it is advisable to maintain a diary of bowel movements, to capture not only frequency but also the size, texture, appearance and other relevant details such as whether the child is experiencing pain or discomfort at any point, retentive posture or stool withholding maneuver or fecal incontinence following constipation. How often a child passes a bowel movement depends on their age. In early infancy, defecation may occur more than 4 times a day. Usually by the age of 4 years, when 98% of children have gained voluntary control of the sphincter, the frequency decreases to 1-2 movements per day.
What’s your advice on toilet training in small children and exercises for older children? Dr Neelam Mohan: Toilet training should not be started before 24 months of age; however, there is a variation in recommended age of training between 3-4 years. Toilet training should be done by one person, who should follow one routine (5 minutes after each major meal), at one place, using one word e.g. pooh/potty etc. For a child with constipation, make the child sit in the toilet, 2-3 times a day for 5-10 minutes after meals (within 30 minutes of meal intake); make the defecation painless by treating anal fissures, if present; sit in squatting position in the Indian toilet or with foot rest in English toilet/potty seat to have appropriate angulation of knees and thighs to facilitate expulsion of stools; plus a reward system (positive reinforcement) helps in motivating the child and avoiding child-parent conflict.
Ensuring adequate physical activity in any form is very important for both digestive health as well as overall health. Some basic daily exercises that can aid better digestion include walking for 30 minutes, 4-5 frog squats and the invisible chair sitting position that helps children stretch their pelvic muscles.
What are the best diet practices for children to have a smooth bowel system? Dr Neelam Mohan: A balanced and healthy diet is important for digestion. Such a diet should include all the major food groups, particularly fruits, vegetables and fibre-rich foods such as cereals, whole pulses with bran, vegetables, salad and fruits. Children should also be encouraged to drink more fluids, especially water, while limiting junk food. Restrict excessive milk and encourage intake of semi solids and solids in younger children.
It’s also a good idea to have your child eat meals on a regular schedule, and to make enough time for meals to allow them to eat at a leisurely pace. Eating a meal will often cause a bowel movement within 30 to 60 minutes. Breakfast in particular should be served early, giving children enough time to have a bowel movement at home before going to school. Even so, if the symptoms of constipation prevail leading the child to experience discomfort, then parents should consult the doctor for a more sustained management of childhood constipation as there are various options available depending on the severity of constipation. Recently, a child friendly innovative option in the form of gummies are available in India which contain the prebiotic lactulose, that helps in digestion besides being a stool softener.
How does constipation impact a child’s life? Dr. Srirupa Das: A healthy digestive system is central to the effective breakdown of food and the timely passage of undigested components through the gastrointestinal (GI) tract, which helps children’s bodies grow normally. 70% of our immune system is active in our digestive system, and 95% of the hormone serotonin (which regulates emotions) is found in the gut.
Feeling good on the ‘inside’ is linked to feeling good on the ‘outside’. It’s important for children to have good digestive health, as a healthy gut contributes to physical growth and mental development, helping them to achieve their full potential. Moreover, constipation can disrupt the toilet training process. Children may also fear passing painful stools, and thus hold their bowel movements, but this in turn hardens the stool and makes it more painful to poop.
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