Constipation in children is relatively common[1] and can contribute to the severity of reflux episodes.[2][3] Up to 1 in 10 children seek medical attention because of constipation. 3 to 5% of all paediatric outpatient and 25% of all paediatric gastroenterology clinic visits are for constipation.[4] Given that all of the top to tail pipes are connected (entire gastro system), it stands to reason that if the bottom is clogged, there is more pressure on the stomach and an increased likelihood that stomach contents may go up rather than down.
Constipation is a relatively benign condition and can be relatively easily treated in consultation with your healthcare professionals. But it can lead to significantly decreased quality of life for children and quite a bit of pain if not treated and over a longer period of time can lead to fear of going to the toilet and other related problems.[7] Fortunately, in most instances, it can be treated quite easily.
It is important to have children evaluated by a medical professional where constipation is a recurrent issue. There are some other serious conditions that can masquerade as constipation and these must be evaluated and treated by a doctor.
What is normal? The poo-gazers guide…
A great resource for considering literally all different colours and consistencies of poo (complete with photos – ick) is available on BabyCentre.com here. It’s a wonderful resource and we’re grateful someone else has done the hard yards in compiling that yucky mess into something (forgive me) “digestible”.
Essentially, the frequency of a child’s poo is not so much the issue. There is genuinely a big difference in frequency between children. What you need to look out for and talk to a doctor about is:
1. Abnormal colour of poo:
- is it black or red? This can be an indication of blood or dried blood coming through the colon and requires immediate medical attention. (Note: if your child is on a prescription formula like Neocate or Elecare you may also get black or greenish poos but still always check with your doctor).
- is it green or mucousy, with white flecks? This can be an indication of some kind of food intolerance and also requires the attention of a doctor or paediatrican. It may also be accompanied by excess wind and wind pain.
- More information from Mayo Clinic (leading US hospital): Stool Colour: When to Worry; and What’s Normal for Baby Poop?
2. Abnormal consistency of poo:
- Is it too hard or soft? This may indicate that the child has a motility issue or is dehydrated. A good way of understanding and describing different
![]( "bristol_stool_chart")
consistency is the Bristol Stool Scale which categorises faecal consistency into 7 simple categories. It can be useful in communicating your concerns to your doctor or in helping childcare or other family members record the motions of your child accurately if there is a problem that requires ongoing monitoring. - Does it contain mucous? As above, this may be an indication of intolerance to certain foods and may require a visit to your doctor.
- Some children who are constipated, or seem to oscillate between constipation and diarrhoea, may be experiencing “overflow diarrhoea” where the only thing able to get around harder pieces sitting in the bowel is liquid.[10] Again, a doctor needs to feel your child’s stomach and bowel area to determine if it is full and whether any distention (bloating) is present. A referral to a paediatric gastroenterologist may be necessary.
- Here is an excellent presentation on the issues by Brisbane-based paediatric gastroenterologist, Dr Francis Connor. Video here.
What types of laxative are there?
There are four main types of laxatives. Those that make stools softer, those that make them bulkier (fibre), those that help push the stool out and those that behave like a lubricant.[5]
Before giving your child a laxative, you should consult with your medical professional. Instructions vary greatly and many are not recommended for small children and babies. For young children, the choice is often to use a laxative that makes stools softer like lactulose or macrogols. A Cochrane Review (gold standard review of medical literature) conducted in 2010 concluded that “Polyethylene Glycol should be used in preference to Lactulose in the treatment of Chronic Constipation… in both adults and children.”[6] This is worth being aware of when consulting your GP regarding use of laxatives in children. Also, Polyethylene Glycol (eg Movicol or Osmolax) is effective and safe for use in children and infants.[7][8]
Why is my refluxer constipated?
There are a few possible reasons:
1. It’s common. Lots of children (and adults) are constipated at various times in their lives.
2. Constipation (or diarrhea) and abdominal pain are listed as side-effects of the main two types of medications used to treat reflux – namely H2 Blockers and Proton Pump Inhibitors (PPIs).[3] Common names for H2 blockers prescribed in Australia are Zantac or Tagamet. Common names for PPIs prescribed in Australia are Losec, Nexium, Somac or Zoton.
3. Given that both gastroesophageal reflux disease (GORD) and constipation can be classified as motility disorders, there is conjecture that some dysfunction with the motility of the gastric system could be the cause of both issues in some patients.[9]
4. In some instances, constipation (and indeed some reflux symptoms) can be caused by low abdominal muscle tone. ie if muscles are a bit floppy around the tummy, its not a long stretch to think they might be a bit floppy and not doing their job properly lower down either.
Printable version Constipation, Motility Disorders and GORD in Children
[1] Bruno Chumpitazi, MD, MPH and Samuel Nurko, MD, MPH; Pediatric Gastrointestinal Motility Disorders: Challenges and a Clinical Update; Gastroenterol Hepatol (N Y). 2008 February; 4(2): 140–148.
[2] Pulsifer-Anderson, B.; The Reflux Book; 2007, pg 13.
[3] Gambino, J; Reflux 101; 2008, pg 11.
[4] Dr F Connor, Guidelines for the Evaluation and Treatment of Constipation in Children; QPGHNS, Nov 2005.
[5] Digestive Health Centre: Other Types of Laxatives; BMJ Group Medical Reference, March 16, 2011.
[6] Cochrane Review; Lactulose versus Polyethylene Glycol for Chronic Constipation (Review); The Cochrane Library, 2010, Issue 7.
[7] Dr F Connor, Paediatric Gastroenterologist; Constipation in Children Failing Treatment: What to do?; University of Qld and Qld Health.
[8] Loening-Baucke, V.; Prevalence, symptoms and outcome of constipation in infants and toddlers; J Peds 2005;146:35
[9] Agrawal S.; Gut Motility Problems in Children; Complex Child E-Magazine, 2008.
[10] Blanch, G.; Reflux Reality: A Guide for Families; Michelle Anderson Publishing, Melbourne, 2010. Ch 13 “Reflux Related Issues” Section on “Bowel Disturbances: Constipation and Diarrhoea” pg 154. Reviewed by Prof Terry Bolin, Gastroenterologist and President, Gut Foundation.
Nurse Practitioner Health Management Protocol for the Management of Paediatric Pain, Royal Children’s Hospital, Brisbane. Version 1.0.
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