Managing Digestion in Children

Written by Niamh Kelly, Registered Dietician

Introduction

Constipation is common in childhood and particularly around back to school time.

What causes constipation?

In most cases of constipation in children, no serious cause is found. Some triggers include:

• Change in toilet environment: Changes in routine, starting school/moving to a new one, or being told to hold on when they feel the urge to go.
• Diet: A diet low in fibre/fresh fruit and vegetables and high in processed foods may worsen constipation.
• Natural gut motility: Some children have slow gut movement.
• Toilet habits: Many children are preoccupied playing and put off going to the toilet. Scheduled toilet time should be included three times a day, every day, to allow for regular visits to the toilet.
• Holding-on behaviour: Some children may “hold on” after a painful or unpleasant experience. Holding on further hardens the poo and makes the next one even more painful.
• Disease: In a very small number of children, diseases such as the absence of normal nerve endings in parts of the bowel, defects of the spinal cord, thyroid deficiency and coeliac disease can cause constipation.

Promoting healthy bowel habits

If a toilet-trained child is constipated, it is important for them to develop the habit of sitting on the toilet regularly.

• Encourage sitting on the toilet after meals/three times per day where possible – even if they do not feel the urge to go. They should stay for around five minutes. Avoiding rushing out the door after breakfast time in the morning in particular.
• Reinforce good behaviours (sitting on and pooing in the toilet) with encouragement and age-appropriate sticker or reward charts. Praise should be given for sitting on the toilet, even if they don’t go.
• Correct posture while sitting on the toilet is important. Encourage the child to put his/her feet flat on the ground or a stool, knees should be higher than hips, lean forward with elbows on knees while pushing.

When to see a doctor

• Constipation in older children that is not resolving.
• Toilet trained child with soiling/faecal incontinence.

Medication

If it is an ongoing problem a doctor may recommend a laxative treatment. Children with ongoing constipation are likely to need laxative medications for some time in addition to establishing healthy bowel habits. Parents often hesitate to start laxatives as they are concerned that the bowel would become “lazy” and dependant on laxatives. It is important to provide reassurance that laxatives such as Macrogols are natural stool softeners and lubricants that help stool move through the bowel.

Possible laxative medications include:

• Osmotic laxatives like Movicol/Laxido (Macrogols) or Lactulose which increase the water in the stool and soften it.
• Stimulants like Senekot or Dulcolax, which stimulate the bowel to get rid of the poo.
• Suppositories like Glycerine and Microlax are placed into the child’s rectum to stimulate emptying. They do not soften the poo in the upper bowel. They are sometimes recommended for severe constipation, but oral laxatives are more effective and less distressing for most children.

Top tip: Add Macrogols to age-appropriate drinks such as water, sugar-free squash, fruit juice. When healthy bowel habits have been well established medication should be weaned very gradually. Stopping laxatives too early is a common cause of reoccurrence of constipation.

A healthy diet

Diet alone will rarely treat ongoing constipation in children. However, a healthy balanced diet should be encouraged in all children to include fruit, vegetables and wholegrain foods and work as a preventative strategy.

• A healthy diet should consist of a combination of soluble (oats, fruit, and vegetables) and insoluble fibre (whole grains and pulses). Both types of fibre soften and enlarge stools which reduce transit times. Change to wholegrain carbohydrate foods such as cereal and bread and advise at least five portions for fruit and/or vegetables per day.

Top tip: A portion of carbohydrate, fruit or vegetables is equal to the child’s fist. Add grated vegetables to sauces or mince dishes, puree fruit to porridge oats / yogurt or introduce a daily smoothie with added fruit, vegetables, nuts, and seeds.

Key Points

• Diet alone will not treat ongoing constipation in children.
• Medications alongside encouraging healthy bowel habits may be required.
• Regular sitting on the toilet after meals is important to develop a good bowel habit. This should be done even if they do not feel the urge to go.
• Movicol must be made up with the correct volume of water. It has a slightly salty taste and can be mixed with fruit juice or cordial.
• Lactulose is a sweet tasting liquid. It can be mixed with water, milk or juice.