Functional
Constipation and Soiling in Children
Patient Education Handout associated with UMHS Clinical Care Guideline
Patient Education Handout associated with UMHS Clinical Care Guideline
|
Functional
Constipation and Soiling in Children
Patient Education Handout associated with UMHS Clinical Care Guideline |
This information is not a tool for self-diagnosis or a substitute for medical treatment. You should speak to your health-care provider or make an appointment to be seen if you have questions or concerns about this information or your medical condition.
What is Constipation?
Constipation is a word used to describe stools (bowel movements) that are passed less often than every three days. This term also describes bowel movements that are hard and/or difficult or painful to pass, even if the person has bowel movements several times per week. Constipation is very common and affects about 30% of children.
Soiling describes the leakage of liquid or formed stool in underwear. Most often, soiling or 'accidents' occur because there has been constipation and, over time, a buildup of stool in the rectum (called an impaction). When constipation and impaction have gone on for many months, changes happen in muscles and nerves in the rectum (the end part of the large intestine) such that many children cannot feel the need to go nor be able to stop stool that may leak out involuntarily.
Constipation and soiling is a common health problem in children. It occurs in 3 to 4 of every 100 children at preschool age and 1 to 2 of every 100 children at school age. Most often, (about 95% of the time in children), the problem starts for one or a combination of several factors such as: diets low in fiber foods and high in constipating foods; not taking enough time to sit and try to pass stool on a routine basis; painful experiences around stool passage; withholding of stools as a result of past discomfort; medications that are constipating; normal developmental features; or a family pattern of slower bowel function. Constipation due to such factors is called ‘functional’.
What is the Treatment?
Over one-half of children with functional constipation and soiling recover after 6 to 24 months of closely following treatment recommendations. The treatment includes:
Medical evaluation.
Teaching for you and your child about the constipation problem.
'Clean out' if there is an impaction of stool in the rectum.
'Maintenance Program' where you and your child work together to take medications, achieve positive toileting behaviors, track stool outputs and increase dietary fiber and clear fluids.
Wean off medication support while maintaining progress in diet and behavioral areas.
I. Clean-out. If your child has a stool impaction, your health care provider will discuss ways for 'clean-out'. Your child's clean-out method will be: ________________________________________________
II. Maintenance program. The purpose of the maintenance program is to help your child achieve complete stool passages every day. This will prevent repeated stool impactions in the rectum and allow the muscles and nerves of the rectum to recover strength and feeling. This recovery requires many months (at least 4 - 6 months). It is important to follow the treatment recommendations every day. The children of families that do, often recover more quickly. The most successful treatment programs use a combination of medication, behavior and dietary approaches.
A. Medications. If your health care provider suggests medications give them every day. It is often easier to remember to give the medicine if it is at the same time or within the same routine every day. Your child's medication, amount and times will be:
____________________________________________________
____________________________________________________B. Behavioral Steps.
Write down all stool outputs (in toilet or accident) on a chart or calendar (see sample chart).
A successful maintenance program = one to two comfortable, mushy stools each day and no soiling 'accidents'. Keep up the good work!
Risk for re-impaction = stools less than every three days, hard and/or large stools, and soiling 'accidents'. Review the chart with your health care provider.
Start positive toileting routines
Many children with chronic constipation and soiling can not feel the urge to pass stool. Therefore, have regular toilet sitting times to help your child have their outputs in the toilet and avoid soiling accidents. It takes patience and positive attention to help children build successful toileting routines.
Direct your child to sit on the toilet 2 to 4 times per day. Use statements rather than questions (e.g., "IT IS TIME to sit on the toilet"). Choose times for sitting which can be routine and calm. Sitting after meals takes advantage of the normal gastro-colic reflex to produce stool.
When your child is sitting on the toilet, be sure his/her feet are firmly placed on a flat surface. This will help your child push out stools. If using an adult-sized toilet, a foot stool may be needed.
Check to see if your child has his/her hands on their knees. Holding on to the toilet seat may increase muscle tension at pelvic floor and make it harder to pass stool comfortably and completely.
Work toward a sit time of about 5 minutes.
Praise your child each time he or she sits on the toilet and for any other helpful behavior.
Maintain a positive outlook.
Privileges and incentive programs are often useful and needed for motivating a child to learn new toileting behaviors.
A privilege is something that happens soon after the desired toileting behavior. For example, if your child cooperates with having a toilet sit at a planned time, then a favorite activity can follow.
Refusal to do the toilet sit could lead to the loss of the favorite activity or privilege until the next planned sit time. Loss of the privilege would be a ‘natural consequence’.
A privilege system works best if the parent is ok with the child achieving the favorite activity or not achieving it.
Other positive incentives such as stickers for younger children should also occur right after the desired behavior.
Older children are often interested in adding up points or stars over many days and "cashing them in" for a special activity or treat.
Begin rewarding your child at a level where he/she can reach some success then move forward (e.g., begin with a reward for sitting; later on, reward for outputs).
C. Diet.
Increase dietary fiber to your child's age in years + 5 every day. For example, a 5 year-old child should have 10 grams of fiber each day. Your health care provider may suggest a higher amount, up to age in years + 10.
The amount of fiber your health care provider recommends is _______________________
Good fiber choices include fiber-rich breads, crackers, cereals, fruits and vegetables
If your child is a picky eater, consider using a fiber supplement
Read all food labels to learn the grams of fiber per serving.
See Fiber Content in Common Toddler Foods or General Fiber Calculations for approximate fiber grams in common foods.
Make sure your child is drinking enough clear fluids -- about 2 ounces of clear fluids for each gram of fiber that you target for your child each day. The best clear fluid is water. So, if your child’s fiber target is 10, then provide at least 20 oz clear fluids daily.
If your child's health care provider agrees, lower the amount of constipating foods in the diet. Constipating foods include milk and other dairy products, bananas and gelatins.
Ask your health care provider about your child’s calcium needs especially if you are limiting dairy intake.
D. Follow up.
Your child's health care provider will arrange for routine visits and contact:
Health care provider's Phone #: ___________________________________
Call the office if your child does not have a good amount of stool out at least every other day, has soiling accidents, has problems agreeing to behavior, diet or medicine advice, or if you have questions.
Resources
Kids books:
Once Upon a Potty (1980) (his and her versions and toy-set available), A. Frankel, Barron's;
Everyone Poops (1984 Japan, 1993 U.S.) T. Gomi, Kane/Miller;
I Have To Go. (1990) A Sesame Street Toddler Book, Random House
Potty Time (1988) A. Civardi, J Langley, Simon & Schuster.
Videos:
It's Potty Time. (1991) Learning Through Entertainment, Video Distributors, Gastonia, N.C., 28052;
Once Upon a Potty, (1980) Barren's Home Video.
Web sites:
UMHS Your Child Website
http://www.med.umich.edu/1libr/yourchild/
Children's Medical Center of the University of Virginia, Multimedia Tutorials for Children and Parents, Chronic Constipation and Encopresis in Children.
http://www.healthsystem.virginia.edu/uvahealth/peds_growth/encopres.cfm
September, 2008