With Dr Janet Chase
Dr Janet Chase is a physiotherapist, academic and a founding member of the Continence Foundation of Australia. She started her career in women's health and has been a clinician in continence care for the past 35 years. “So many of the adults I was seeing said to me, ‘you know, this has always been a problem for me since I was a child’. So, I thought, why aren’t we treating the children?”
Constipation and faecal incontinence are common in children, but these symptoms are important to address from an early age because they are a risk factor for other conditions such as urinary incontinence, prolapse and pelvic pain in adulthood. It is best to seek help early.
What causes these difficulties in children?
Janet explains that the most common reason for constipation in children is functional. This means that there is no underlying disease, but there is an underlying cause. Most commonly it is a natural response to previous painful experiences. Children with constipation may have had a distressing experience, such as nappy rash or a painful bowel evacuation and the result is that they instinctively avoid going. This then causes constipation and bowel dysfunction. It can happen without parents realising.
“Children are really incredibly sensible. If something happened once and they didn't like it or it hurt, they don't want to do it again” states Janet. Some of the less common reasons for childhood bowel conditions are coeliac disease, inflammatory bowel disease and food sensitivity. These kinds of conditions account for less than 5% of children with constipation.
What should I look out for?
Signs of constipation in children from three years old include
- Infrequent emptying of bowel or difficulty emptying the bowel
- Abdominal pain, ‘a sore tummy’ or flatulence
- A decreased appetite: they may become really picky eaters
- Children may be unhappy, bad-tempered, tired or withdrawn, because they do not feel well
- When they need to empty the bowel these children may go off and hide, or disappear behind the couch, they might stand up and hold on to furniture. They may appear to be straining to have a bowel action, but they are really straining not to have a bowel action
- They might have separation anxiety and just want to stay with mum or dad
- Toilet trained children may have faecal incontinence, which can be mistaken for diarrhoea.
Who can I go to for help?
The first thing to do is get an examination and assessment by someone who is trained to do so. This includes medical practitioners, nurse continence specialists with paediatric experience and pelvic health physiotherapists with paediatric experience.
With the help of a trained health care professional, most of these difficulties can be resolved and initial improvements can happen very quickly.
How is it treated?
Different treatment is required for constipation in children than in adults.
For a loaded bowel, treatment usually involves laxatives. Not treating constipation can harm the bowel, however treating constipation with laxatives designed for children is very safe and these laxatives can be used long term.
The condition may improve in just a few weeks, but difficulties can reoccur if treatment stops. It is usually best to continue for a few months, because there are big changes happening for the child, for example the child may need to
- Develop more understanding of how their body works
- Learn to respond to the feelings in their body (there may be no sensation from their bowel and that takes time to redevelop)
- Change their day-to-day actions in response to those feelings.
All of this takes time. Sometimes symptoms may reappear, but as the child grows and learns to understand their body better, they and their parents will be able to detect the symptoms of relapse and intervene earlier. If there is no progress over six months, then the child should see a paediatric gastroenterologist. There are some children who will have difficulties and need treatment for years.
What is happening in children’s digestive systems?
Children generally have very strong pelvic muscles, so they are quite successful at holding on. Unfortunately, holding on and not having a bowel movement makes the condition worse. “They’re holding on for dear life and children, on the whole, have very efficient pelvic muscles, so they are quite successful at doing this. This, however, slows the gut down and then it’s likely that the discomfort will be repeated, which reinforces the behaviour” states Janet.
Understanding some of the ways the digestive system works can help us to respond. For example, children may have the urge to go to the toilet at about the same time each day. About 15 to 30 minutes after eating a child will have a gastrocolic reflex; this causes a big squeeze to happen in the bowel or colon, that moves the contents down the bowel towards the rectum (the last part of the bowel). A child is likely to get the urge to go to the toilet at around this time.
“If that reflex is happening after breakfast and the child is in the car being taken to childcare, the feeling might go away and the child misses out on going to the toilet after breakfast. It can help to be aware of that and make sure that at that time the child does have access to a toilet,” mentions Janet.
Preventative strategies
We can all experience constipation from time to time when something in our lives affects our bowel function. Travelling, a change in diet, a change in routine, an emotional upset or stress can affect all of us. Janet says that children are no different. “One of the things that parents can do early on is teach their child to go when they feel like they need to go to the toilet. Stop what you are doing and go to the toilet, don't put it off. Because the feeling of needing to go might go away but the bowel content doesn't go away.”
Good nutrition, including plenty of fruit and vegetables, and timely toilet training can also help. Late toilet training has been associated with a higher rate of childhood constipation. Janet assures parents that these difficulties can be addressed and that treatments are well established and very effective as “hundreds of times, parents and their sad little child will come in to see you. And then you assess them and set them on the right path and at the next appointment the child comes bouncing in with a smile on their face. It can change within one session; once the underlying issues are worked out and everyone understands.”