Constipation

Definition

Constipation is an acute or chronic condition in which bowel movements occur less often than usual or consist of hard, dry stools that are painful or difficult to pass. Although constipation is a relative term, with normal patterns of bowel movements varying widely from person to person, generally an adult who has not had a bowel movement in three days or a child who has not had a bowel movement in four days is considered constipated. Infants who are still exclusively breastfed may go seven days without a stool.

Description

The colon (the large intestine) absorbs water while forming waste products (the stool) from digested food. Muscle contractions in the colon (peristalsis) push the stool toward the rectum. By the time the stool reaches the rectum, it is solid because most of the water has been absorbed. However, hard, dry stools and constipation occur when too much water is absorbed by the colon from the stool, which can result from the muscle of the colon contracting too slowly. Constipation is also referred to as irregularity of bowels or lack of regular bowel movements.

Constipation can occur at any age and is more common among individuals who resist the urge to move their bowels at their body's signal. This often happens when children start school or enter daycare. They may feel shy about asking permission to use the bathroom, they may be involved in more enjoyable activities and may not want to stop, or they may be rushed when using the bathroom and not have time to complete the bowel movement. Once constipation has developed and bowel movements become painful or more difficult, the child will attempt to go even less often, and the constipation will worsen.

Although this condition is rarely serious, it can lead to the following:

• tearing of the mucosal membrane of the anus (especially in children), which can cause bleeding and the development of an anal fissure
• bowel obstruction
• chronic constipation
• hemorrhoids (a mass of dilated veins in swollen tissue around the anus)
• hernia (a protrusion of an organ through a tear in the muscle wall)
• spastic colitis ( irritable bowel syndrome , a condition characterized by alternating periods of diarrhea and constipation)
• laxative dependency

Less commonly, chronic constipation may be a symptom of colorectal cancer , depression, diabetes, diverticulosis (small pouches in the muscles of the large intestine), lead poisoning , or Parkinson's disease (in adults) and should be investigated by a doctor.

Demographics

Constipation is a common complaint in children, occurring in up to 10 percent of youngsters. It accounts for approximately 3 percent of pediatric outpatient visits and 25 percent of visits to a pediatric gastroenterologist.

Causes and symptoms

Constipation usually results from not getting enough exercise , not drinking enough fluids (especially water), delays in going to the bathroom when there is the urge to defecate, or from a diet that does not include an adequate amount of fiber-rich foods such as beans, bran cereals, fruits, raw vegetables, rice, and whole-grain breads. Eating too many dairy products such as milk, cheese, yogurt, and ice cream may also result in harder stools. Constipation in children often occurs when they hold back bowel movements for various reasons, such as when they are not ready for toilet training or are afraid of toilet training.

Other less common causes of constipation include anal fissure (a tear or crack in the lining of the anus); chronic kidney failure; colon or rectal cancer; depression; hypercalcemia (abnormally high levels of calcium in the blood); hypothyroidism (underactive thyroid gland); illness requiring complete bed rest; and irritable bowel syndrome. Stress and travel can also contribute to constipation, as well as other changes in bowel habits.

Constipation can also be a side effect of the use of the following medications, many of which are not commonly used by children:

• aluminum salts in antacids
• antihistamines
• antipsychotic drugs
• aspirin
• belladonna ( Atopa belladonna, a source of atropine, a medication used to relieve spasms and dilate the pupils of the eye)
• beta blockers (medications used to stabilize irregular heartbeat, lower high blood pressure, and reduce chest pain )
• blood pressure medications
• calcium channel blockers (medication prescribed to treat high blood pressure, chest pain, some types of irregular heartbeat and stroke , and some non-cardiac diseases)
• diuretics (drugs that promote the formation and secretion of urine)
• iron or calcium supplements
• narcotics (potentially addictive drugs that relieve pain and cause mood changes)
• tricyclic antidepressants (medications prescribed to treat chronic pain, depression, headaches, and other illnesses)

A child who is constipated may feel bloated, have a headache , swollen abdomen, or pass rock-like feces; or strain, bleed, or feel pain during bowel movements. A constipated baby may strain, cry, draw the legs toward the abdomen, or arch the back when having a bowel movement. Newborns and young infants may also strain, turn red in the face, grunt and draw legs up when passing normal, soft stool. If the stool is not hard (rabbit pellet in consistency), then these infants are not considered constipated.

When to call the doctor

Most people become constipated once in a while, but a doctor should be contacted if significant changes in bowel patterns last for more than a week or if symptoms continue more than three weeks after increasing activity and fiber and fluid intake.

In addition, a doctor should be called if an infant younger than two months is constipated, or if an infant (except those that are exclusively breastfed) goes three days without a stool. If vomiting or irritability is also present, then the doctor should be called immediately. A doctor should also be consulted if a child is holding back bowel movements (in order to resist toilet training) or whenever constipation occurs after starting a new prescription, vitamin, or mineral supplement or is accompanied by blood in the stools, changes in bowel patterns, fever , and rectal or abdominal pain.

Diagnosis

The child's symptoms and medical history help a primary care physician to diagnose constipation. The doctor uses his fingers to see if there is a hardened mass in the abdomen and may perform a rectal examination. Other diagnostic procedures include a barium enema, which reveals blockage inside the intestine; laboratory analysis of blood and stool samples for internal bleeding or other symptoms of systemic disease; and a sigmoidoscopy (examination of the sigmoid area of the colon with a flexible tube equipped with a magnifying lens).

Treatment

Constipation is usually a temporary problem in children and no cause for concern. A child with constipation should be instructed to drink an adequate amount of water each day (six to eight glasses), exercise on a regular basis, and eat a diet high in soluble and insoluble fibers. Soluble fibers include pectin, flax, and gums; insoluble fibers include psyllium and brans from grains like wheat and oats. Fresh fruits and vegetables contain both soluble and insoluble fibers. Dietary fiber intake should be increased gradually, along with an increase in water consumption, in order to produce soft, bulky stools.

Constipation in infants may be treated by the following:

• if over two months of age, feeding the infant 2–4 ounces (60–120 ml) of fruit juice (grape, pear, apple, cherry, or prune) twice a day
• if over four months of age and the infant has begun solid foods, feeding the baby foods with high fiber content (such as peas, beans, apricots, prunes, peaches, pears, plums, and spinach) twice a day

If changes in diet and activity fail to relieve occasional constipation, an over-the-counter laxative may be used for a few days. Preparations that soften stools or add bulk (bran, psyllium) work more slowly but are safer than Epsom salts and other harsh laxatives or herbal laxatives containing senna ( Cassia senna ) or buckthorn ( Rhamnus purshianna ), which can harm the nerves and lining of the colon. A child who is experiencing abdominal pain, nausea , or vomiting should not use a laxative. Laxatives should not be used for a long period, because the child can become dependent on them.

A warm-water or mineral oil enema can relieve constipation in children with severe or stubborn cases of constipation. However, laxatives or enemas should not be given to children without instruction from a doctor.

If a child has an impacted bowel, the doctor can insert a gloved finger into the rectum and gently dislodge the hardened feces.

Alternative treatment

Castor oil, applied topically to the abdomen and covered by a heat source (a heating pad or hot water

bottle) can help relieve constipation when used nightly for 20 to 30 minutes.

Acupressure

This needleless form of acupuncture is said to relax the abdomen, ease discomfort, and stimulate regular bowel movements when diet and exercise fail to do so. After lying down, the child closes his or her eyes and takes a deep breath. For two minutes, the child or parent applies gentle fingertip pressure to a point about 2.5 in (14 cm) below the navel.

Acupressure can also be applied to the outer edges of one elbow crease and maintained for 30 seconds before pressing the crease of the other elbow. This should be done three times a day to relieve constipation.

Aromatherapy

Six drops of rosemary ( Rosmarinus officinalis ) and six drops of thyme ( Thymus spp.) diluted by one ounce of almond oil, olive oil, or another carrier oil can relieve constipation when used to massage the abdomen.

Herbal therapy

A variety of herbal therapies can be useful in the treatment of constipation. Several herbs, including chamomile ( Matricaria recutita ), dandelion ( Taraxacum mongolicum ), and burdock ( Arctium lappa ), act as bitters, stimulating the movement of the digestive and excretory systems.

Homeopathy

Homeopathy also can offer assistance with constipation. There are acute remedies for constipation that can be found in one of the many home remedy books on homeopathic medicine. A constitutional prescription also can help rebalance someone who is struggling with chronic constipation.

Massage

Massaging the leg from knee to hip in the morning, at night, and before trying to move the bowels is said to relieve constipation. There is also a specific Swedish massage technique that can help relieve constipation.

Yoga

The knee-chest position, said to relieve gas and stimulate abdominal organs, involves the following:

• standing straight with arms at the sides
• lifting the right knee toward the chest
• grasping the right ankle with the left hand
• pulling the leg as close to the chest as possible
• holding the position for about eight seconds
• repeating these steps with the left leg

The cobra position, which can be repeated as many as four time a day, involves the following:

• lying on the stomach with legs together
• placing the palms just below the shoulders, holding elbows close to the body
• inhaling, then lifting the head (face forward) and chest off the floor
• keeping the navel in contact with the floor
• looking as far upward as possible
• holding this position for three to six seconds
• exhaling and lowering the chest

Prognosis

Changes in diet and exercise can often eliminate constipation. However, childhood constipation can sometimes be difficult to treat when a child, after having a painful experience, makes a decision to resist and delay going to the bathroom. These cases often require prolonged support, explanation, and medical treatment.

Prevention

Avoiding constipation by making lifestyle changes is easier than treating it. Most American adults only consume between 11 to 18 grams of fiber a day, but to prevent constipation, consumption of 30 to 35 grams of fiber (an amount equal to five servings of fruits and vegetables, and a large bowl of high-fiber cereal) and between six and eight glasses of water each day can generally prevent constipation. A suggested goal for dietary fiber intake during childhood and adolescence is consumption in grams equivalent to the age of the child plus 5 grams per day.

Sitting on the toilet for 10 minutes at the same time every day, preferably after a meal, can induce regular bowel movements. This may not become effective for a few months, and it is important to defecate whenever necessary.

Fiber supplements containing psyllium ( Plantago psyllium ) usually become effective within about 48 hours and can be used every day without causing dependency. Powdered flaxseed ( Linium usitatissimum ) works the same way. Insoluble fiber, like wheat or oat bran, is as effective as psyllium but may give the child gas at first.

Parental concerns

Constipation can be a frustrating problem for both children and their parents. Parents need to work closely with the doctor to determine why the child is constipated and to develop an appropriate treatment strategy.

Resources

BOOKS

Bernard, H. The Homoeopathic Treatment of Constipation. New Delhi, India: B. Jain Publishers Pvt. Limited, 2003.

Peiken, Steven R. Gastrointestinal Health: The Proven Nutritional Program to Prevent, Cure, or Alleviate Irritable Bowel Syndrome (IBS), Ulcers, Gas, Constipation, Heartburn, and Many Other Digestive Disorders. London: Harper Trade, 2005.

Whorton, James C. Inner Hygiene: Constipation and the Pursuit of Health in Modern Society. Collingdale, PA: DIANE Publishing Co., 2003.

WEB SITES

"Constipation." MedlinePlus. Available online at http://www.nlm.nih.gov/medlineplus/constipation.html (accessed December 9, 2004).

Judith Sims Maureen Haggerty