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.

Spanish version

What is Constipation?

Constipation is a term used to describe stools or bowel movements that are passed less often than every two days. This term also describes bowel movements that are hard and/or difficult or painful to pass, even if the person has bowel movements many times per week. Constipation is very common and affects 16 to 37% of children.

Soiling describes the passage of liquid or formed stool in between larger stool outputs. Most often, soiling or 'accidents' occur because there has been constipation and over time, a buildup of stool in the rectum (called an impaction). With chronic constipation, changes occur in muscles and nerves such that many children cannot feel the need to go nor stop stool that may leak out by mistake. For children who have had a constipation and soiling problem for a while, the soiling may occur often.

Constipation and soiling is a common health problem. 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 is called 'idiopathic' or functional constipation and soiling. This means that the constipation problem may have started for one or a group of factors such as: diet low in fiber foods and high in constipating foods; not taking the time to sit and try to pass stool on a routine basis; painful experiences around toileting, such as painful stool passage in the past; withholding of stools as a result of past discomfort; medications that are constipating; developmental features; and a family pattern of slower bowel function.

What is the Treatment?
Over one-half of children with functional constipation and soiling recover after 6 to 24 months of closely following treatment advice. Treatment includes:

• Medical evaluation.
• Teaching for you and your child about constipation.
• 'Clean out' if there is an impaction of stool in the rectum.
• 'Maintenance' - you and your child will work together to support positive toileting behavior, track stool output, increase dietary fiber, and take medications.

I. Clean-out. If your child has a stool impaction, your doctor will discuss methods for 'clean-out'. Your child's clean-out method will be:
________________________________________________

II. Maintenance program. The purpose of the maintenance program is to keep stools moving on a routine basis... This will prevent re-impaction of stool in the rectum and allow the muscles and nerves of the rectum to recover strength and feeling...
A. Behavioral Steps.

1. Write down all stool passage on a chart or calendar (sample chart provided).
   One to two comfortable, mushy stools each day, and no soiling 'accidents' indicate a successful maintenance program. Keep up the good work. Stools less than every two days, hard and/or large stools, and soiling 'accidents', show a high risk for re-impaction. Review the plan with your doctor.
   
   
2. Start positive toileting routines
   It takes patience and positive attention to help a child build successful toileting routines. Getting to the toilet often is key first step. Give your child praise for each sitting and for any other helpful behavior. Use a chart to writ down each sitting time. Positive support for toilet sitting will help later successes come more easily.
   
   Many children with chronic constipation and soiling can not feel the urge to stool. Therefore, ask your child to sit on the toilet 3 to 4 times per day, 5 - 10 minutes each. Give positive advice to sit (e.g., "It is time to sit on the toilet"), and reminders about the 'business' of toileting. Choose times for sitting which can be routine and calm. Sitting after meals takes advantage of the normal gastro-colic reflex to produce stool.
   
   Provide foot support, so that your child's feet are firmly placed on a flat surface. This will help your child push out stools.
   
   
3. Maintain a positive outlook.
   Incentives or privileges are often useful and needed along with charts to motivate a child . For example, toilet sitting at a planned time then allows a favored activity to follow. If the child refuses to toilet sit this could lead to the loss of the favored activity until the next planned sitting. This is a natural consequence.
   
   Other positive incentives such as stickers for younger children should occur right after the desired behavior. Older children are often interested in adding up points or stars overmany 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.
   
   
4. Avoid punitive approaches and embarrassment.
   Be supportive and respectful but tell your child what you expect. Expressions of anger toward your child, shaming or embarrassing your child are not helpful, and can make matters worse.

B. Diet. Provide fiber food choices to improve stool regularity for all family members.

1. Increase fiber to give a daily amount equal to at least the child's age in years + 5 For instance, a 5 year-old child should have 10 grams of fiber each day. Your doctor may suggest a higher amount, up to age in years + 10. This can include (see also fiber list):
   • Fiber rich breads, crackers, cereals, fruits (raisins, dates, prunes, pears, cantaloupe) and vegetables (broccoli, beans, corn, peas, popcorn). Add unprocessed wheat bran to favorite foods (peanut butter, pudding, oatmeal).
   • Read the food labels for grams of fiber/serving.
   • Assure enough fluids - about 2 ounces of non-dairy fluids for each gram of fiber.
2. Prepare the fiber foods so that they are easy for the whole family to obtain and eat.
3. If your child's doctor agrees, lower the amount of constipating foods in the diet: Milk and other dairy products. (Note, it is important to maintain 2 - 3 cups of dairy if able. In some cases, your child's doctor might suggest a calcium supplement instead of dairy foods or suggest adding one.
   • Jell-O, rice, junk-foods, chocolate

C. Medications. If your doctor suggests medications give them at routine times every day. Your child's medication, amount and times will be: ____________________________________________________

D. Follow up. Your child's doctor will arrange for routine visits and contact:
Doctor's Phone #: ___________________________________
Call your office if your child:

Does not have a good amount of stool out every day, has soiling accidents, has problems agreeing to behavior, diet or medicine advice, or if you have questions.

Resources
Parent books:
Childhood Constipation and Soiling. (1995) J. Owens-Stively
Children's Hospitals and Clinics Family Resources Department, 2525 Chicago Avenue South, Minneapolis, MN 55404 (612-813-6816).
Toilet Training. (1984, revised 1993) V. Lansky, Bantam Books

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.

Websites:
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

UMHS Your Child Website
http://www.med.umich.edu/1libr/yourchild/

Name ___________________________

BOWEL MOVEMENT MONITORING SHEET
Please complete this sheet by filling in date and time of day each time your child
1) Has a soiling-accident
2) Sits on toilet and BM ?
3) BM or soiling size (small, medium, large amount) quality (formed, mushy, liquidy, soft/hard)
4) Stickers for Toilet sit and/or BM.

Date & Time	Soiling - Accident	Toilet sit BM ?	BM or soiling Size & Quality	*Stickers or Stars*

Fiber Calculations

FRUITS                                                 SERVING                             FIBER (gm)

Apple w/skin                                                        1 med                                       3.7
Apple without skin                                              1 med                                       2.4
Applesauce                                                           ½ cup                                      2.0
Apricots                                                                 3 med                                       2.5
Banana                                                                   1 med                                       2.7
Blueberries (raw)                                                  1 cup                                        4.0
Cantaloupe                                                            1 cup pieces                           1.3
Cherries                                                                 10 cherries                              1.3
Fruit salad/fruit cup                                            ½ cup                                       1.3
Grapefruit                                                              ½ med                                      1.3
Grapes                                                                    1 cup                                       1.2
Honeydew melon                                                 1 cup pieces                           1.0
Mandarin oranges                                               ½ cup                                       1.0
Nectarine                                                               1 med                                       2.2
Orange                                                                   1 med                                        3.0
Peach                                                                     1 med                                        1.7
Pear                                                                        1 med                                        4.0
Pineapple                                                               1 cup pieces                           2.0
Plum                                                                       1 med                                        1.0
Prunes (dried)                                                       10 prunes                                 6.0
Raisins (seedless)                                                2/3 cup                                     4.0
Raspberries                                                           1 cup                                        8.4
Strawberries                                                          1 cup                                        3.4
Tangerine                                                              1 med                                        2.0
Watermelon                                                          1 cup pieces                             0.8

VEGETABLES                                     SERVING                    FIBER (gm)

Artichoke, boiled                                                 1 medium                                 6.2
Asparagus, boiled                                               ½ cup, 6 spears                      1.4
Baked beans                                                         1 cup                                      14.0
Broccoli, boiled                                                    ½ cup                                       2.3
Brussels sprouts, boiled                                     ½ cup                                       2.0
Carrots                                                                   1 medium                                 2.0
Cauliflower, boiled                                               ½ cup                                       1.7
Celery                                                                     1 stalk (7 inch)                        0.7
Coleslaw                                                                ½ cup                                       1.0
Corn, on the cob                                                  1 ear                                          2.0
Cucumber                                                              ½ cup of slices                        0.5 
Eggplant, boiled                                                   ½ cup                                        1.0
Green beans, boiled                                             ½ cup                                       2.0
Lima beans, boiled                                               1 cup                                      13.2
Lettuce                                                                   ½ cup of pieces                      0.5
Mushrooms                                                          ½ cup pieces                           0.4
Onions, boiled                                                      ½ cup                                       1.0
Peas, green                                                            ½ cup                                       4.0
Pinto beans, boiled                                               1 cup                                      14.7
Potato, baked w/skin                                            1 medium                                 5.0
Potato, boiled                                                        1 medium                                 2.0
Potato salad                                                          ½ cup                                       1.6
Pumpkin, canned                                                  ½ cup                                       5.0
Spinach, boiled                                                     ½ cup                                       2.2
Spinach, raw                                                         ½ cup                                        0.8
Squash, winter                                                      ½ cup                                       3.0
Sweet potato, baked                                             1 medium                                 3.0
Tomato, raw                                                           1 medium                                 1.0

All-Bran, Kellogg’s                                               ½ cup                                     10.0
Alpha-Bits                                                              1 cup                                         1.0
Banana Nut Crunch                                              1 cup                                         4.0
Bran Buds, Kellogg’s                                           1/3 cup                                    12.0
Cheerios                                                                  1 cup                                         3.0
Corn Pop                                                                 1 cup                                         0.0
Cracklin’ Oat Bran, Kellogg’s                              ¾ cup                                       5.6
Cream of Wheat                                                      1 pack                                      1.0
Fiber One, General Mills                                        ½ cup                                     13.0
Frosted Mini-Wheats                                            5 biscuits                                 5.0
Honey Nut Cheerios, GMills                                1 cup                                         2.0
Instant Oatmeal                                                      1 pack                                       3.0
Multi-Grain Cheerios                                             1 cup                                         3.0
Quaker Shredded Wheat                                       3 biscuits                                 7.3
Raisin Bran, General Mills                                     ¾ cup                                       3.0
Raisin bran, Kellogg’s                                            1 cup                                        8.2

(Check the packages!! Many brands have different fiber amounts)

Bagel (most bagels)                                          1 Bagel                                     1.5
English Muffin, Thomas                                  1 muffin                                    1.5
French bread                                                      1 slice                                       0.5
Italian, Bakery Light                                          1 slice                                       2.5
Multi-grain                                                          1 slice                                       1.5
Pancakes                                                             1 med-large                              1.0
Pita, white                                                            1 6”dia                                     1.0
Seven grain, Bran’ola                                        1 slice                                       3.0
Wheat, Bakery Light                                         1 slice                                       2.5
White                                                                   1 slice                                       1.0
Whole wheat                                                       1 slice                                      2.0

PASTA                                              SERVING                   FIBER(gm)

Elbow macaroni, Golden Grain                         ½ cup                                       2.0
Macaroni                                                             1 cup                                        1.8
Macaroni, whole wheat                                     1 cup                                        4.0
Spaghetti, whole wheat                                     1 cup                                        6.3
Brown rice, long grain                                       1 cup                                        3.5
White rice                                                            1 cup                                        1.0

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