Constipation

Dear Lisa,

My son is 12 months old and has had constipation problems since he was about six weeks despite the fact that he is a breastfed baby. His doctor is completely unconcerned and simply advised giving him juice with no further inquiries. Now my son is eating three complete meals a day along with breast milk and the food seems to come out quite a few days later. Now not only is he constipated but he is also beginning to pass stools that are hard, dry and black with a fine sandy texture surrounding them. I don’t believe it is anything I am feeding him but I am not sure. Am I overreacting or should I be worried?

“Worried about Constipation”,

Dear “Worried about Constipation”,

The term Constipation is often defined differently by parents and Physicians. (1) Some parents believe their child is constipated if a bowel movement does not occur in an expected timeframe. The frequency of bowel movements alone does not necessarily define constipation. Normal patterns can range from having several bowel movements per day to having one bowel movement every few days.(2)

The amount of time that stool takes to travel through the bowels and out the rectum is called the transit time. Every person’s body has a different colonic motility pattern which dictates their transit time. Some people’s transit time is slower than others. For people with slow transit time, it takes longer for the stool to travel through the intestinal tract. The longer it takes for the stool to travel through the digestive tract; more water is reabsorbed from the stool and put back into the body. Therefore if a child has a long transit time their bowel movements are expected to be infrequent and their stool is expected to be firm.

Colonic motility can be variable and influenced by other factors such as; sleep, meals, physical activity and emotional stress.(3) Therefore at times a child’s pattern can change dependent upon these variables. Children who have an abnormally slow transit time can develop Constipation. Symptoms of this type of Constipation include an infrequent urge to defecate, infrequent stools, bloating and abdominal discomfort.(4) Children with slow transit Constipation can benefit from the addition of fiber to their diet. Adding fiber to the diet increases stool weight and water content.

Actually, Constipation is defined as difficulty passing hard stools, pain with defecation and a decrease in the frequency of bowel movements. Streaks of red blood are also a common finding in children who are constipated because the passage of hard stools can cause a fissure or a small cut. This fissure bleeds and as a result streaks of red blood can be found on the outside of formed stool.(2)

Perhaps your Doctor seemed unconcerned about the infrequency of your son’s bowel movements because this could be normal for him and because he had no other symptoms. It is common for some children to have infrequent stools. As long as the stool comes out soft and there is no pain or straining it is not considered to be a problem. Now that your son is developing new symptoms such as hardness in texture and a black color this needs to be addressed.

In most cases, Constipation in childhood is acquired and due to changes in diet.(2) There are certain foods that can bind a child’s stool and other foods that may loosen a child’s stool. Every child is different and has a different response to the addition to a new type of food. For many children rice, soy and bananas are binding and can lead to hard stools. On the other hand fruits, fibrous vegetables, bran flakes and oatmeal can loosen a child’s stool. If your child’s stool consistency has changed since the introduction of solids you may want to keep a diary in order to determine if a certain type of food is changing the texture in his bowel movements.

In some cases Constipation can be due to a secondary cause. In other words a different condition can cause a child to develop Constipation. Constipation can be caused by a metabolic or endocrine disorder such as Hypothyroidism, due to a neurologic cause such as Muscular Dystrophy or because of a gastrointestinal disorder such as Celiac disease.(5) Other potential causes in childhood include central nervous system disorders, muscle disorders, mechanical obstruction or side effects to medication.(5)

Hirschsprung disease may be a consideration in a child who has had constipation since birth.(2) Hirschsprung disease is a condition that occurs due to the absence of ganglion cells in a child’s distal intestine.(6) This leads to ineffective colonic motility, constipation and obstruction. About 50 to 90% of cases are detected in the neonatal period.(6) Symptoms demonstrated in the newborn period include feeding intolerance, bilious vomiting and delayed passage of meconium.(7)

Typically 95% of full term infants pass meconium (first stool which is black and tarry in nature) within the first 24 hours of life. Fewer than 10% of children with Hirschsprung disease pass meconium within this timeframe.(6) Just because an infant has normal bowel movements during the neonatal period does not exclude the possibility of Hirschsprung disease. There certainly are a number of children who have a normal history of neonatal bowel movements who ultimately are found to have Hirschsprung disease.(8)

In some cases Hirschsprung disease is diagnosed at a later age.(8) In particular, breastfed infants with Hirschsprung disease have been found to be diagnosed later in the first year of life.(8) Other signs of Hirschsprung disease in an older child include; a history of intermittent abdominal distention and failure to have a bowel movement without the aid of an enema or laxative.(2) If this is the case it would be important to discuss this possibility with your Physician.

If your son is having straining or pain with his stooling, the stool consistency remains hard after dietary manipulation or he has black stools he should be evaluated by his Physician. If this is the case, it would be a good idea to bring a stool sample to the doctor’s office so that he can see the consistency and test it for blood. If it is determined that your son has Constipation this would be a good time to discuss dietary management and the possibility of secondary causes. In some cases a child with Constipation not responsive to dietary manipulation may need to be prescribed medication or referred to a Gastroenterologist for an evaluation.

If you are interested in reading other Pediatric Advice stories covering topics discussed:

Infant Constipation

Treatment for Constipation

Stool Color

Celiac Disease

Stool Withholding

References:
(1)Pare P, Ferrazzi S, Thompson WG, Irvine EJ, Rance L. An epidemiological survey of constipation in Canada; definitions, rates, demographics and predictors of health care seeking. Am J Gstroenterol. 2001.96:3130-3137.
(2)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc. 1990:179-180.
(3)Rao SSC. Constipation evaluation and treatment. Gastroenterol Clin North Am. 2003.32:659-683.
(4)Lembo A, Camilleri M. Chronic constipation. N Engl J Med. 2003.349:1360-1368.
(5)Borum ML. Constipation; evaluation and management. Prim Care. 2001.28:577-590.
(6)Dasgupta R, Langer JC. Hirschsprung disease. Curr Probl Surg. 204;41:942-988.
(7)Kamat D. Hirschsprung Disease. Consultant for Pediatricians. 2006. March:190-191.
(8)Listernick R. A 4-month-old Girl with Bilious Emesis. Pediatric Annals. 2006. 35(7):470-477.


Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice-Your Questions Answered