Childhood Constipation Toddler/Children

Transcription

1 Childhood Constipation Toddler/Children Public Health Nursing and Community Nutrition Services Interior Health Authority February 2013 Feedback welcome to 1

2 Developed by: Sandy Feil, R.N. BScN. Public Health Nurse, Interior Health Cathy Richards, Community Nutritionist, Interior Health Reviewed by: Dr. Shari Claremont, Family Physician Dr. Mark Duncan, Pediatrician Dr. Thomas Kinahan, Urologist Dr. Kim Burrows, Pediatrician Approved by: Nadine Johnson, Practice Lead Promotion and Prevention, Community Integrated Health Services, Interior Health Dr. Gerarda Cronin, Medical Director, Perinatal and Child Health Network, Interior Health 2

3 Table of Contents Introduction... 4 What is constipation... 4 Symptoms of constipation... 4 Encopresis... 5 What causes constipation... 6 The digestive system... 6 Management of Constipation... 7 Routine... 7 Listening.Signs to Watch For... 8 Daily bowel diary... 9 Nutrition Medication Activity School Tips Pulling it all together Glossary of Terms Resources for parents Informational Websites Books References

4 The purpose of this booklet is to help you better understand and manage your child s constipation. It is meant to help you when you talk with a health care professional (doctor, nurse, dietitian, nurse practitioner). A daily routine including good nutrition, medication, activity and positive parenting all play an important role in treating childhood constipation. What is Constipation? Constipation in children is defined as a delay or difficulty in defecation, present for two or more weeks, and sufficient to cause significant distress to the patient. * Symptoms of Constipation INTRODUCTION Many symptoms can occur with childhood constipation: dry, hard painful bowel movements very large bowel movements fear of passing a bowel movement or even sitting on the toilet blood mixed in the bowel movement, caused by small rips or tears at the anal opening (called anal fissures). These are very painful and often take a long time to heal poor appetite abdominal pain, cramps and bloating being bad tempered feeling sick and/or throwing up frequent peeing and bladder infections tensing the stomach or bottom to try to prevent having a bowel movement encopresis 4

5 Encopresis (Soiling) Encopresis, or soiling is a common result of long term constipation. As the large intestine becomes more and more stretched, liquid stool from the small intestine leaks around the hard formed stool in the colon. This will appear as accidents in their underwear. This is often upsetting for both parents and children. Children have no control over these accidents. Don t be surprised if your child denies having soiled themselves as (s)he often will not have noticed there is stool in their underpants. What Causes Childhood Constipation? 97% of the time, the cause of constipation is not known. A child with constipation should be checked out by a doctor or nurse practitioner (NP) to rule out any medical causes. Most times, there is no medical cause. There are many triggers for constipation: having one hard or painful bowel movement (BM), and then being afraid of the next urge to have a BM a negative toilet training experience feeling stressed a change in regular routine not drinking enough fluids some medications Constipation can sometimes go on for awhile before it is recognized. 5

6 The Digestive System It helps when parents and school aged children understand how the body breaks down food (the digestive system) and what happens in the body when constipation happens. Use the picture below to help you understand the digestive system. You may also want to review it with your health care professional. Esophagus (throat) Food moves from the mouth down the esophagus into the stomach Stomach Mixes food with digestive juices Small Intestine (small bowel) About 20 feet long. It absorbs nutrients from food into the bloodstream to give the body energy It sends digested food to the large intestine Rectum Muscular tube that holds stool until the body is ready to have a bowel movement Large Intestine (large bowel-colon) is about 5 feet long -absorbs water from the digested food and forms the stool 6

7 MANAGEMENT OF CONSTIPATION Routine The urge or feeling to have a bowel movement usually occurs 1-2 times a day as stool moves into the empty rectum and stretches it. Usually the body sends this message to the brain about minutes after eating. Having your child practice sitting on the toilet after eating breakfast and supper will help to train the bowel to respond to this call. If you do not respond to the message, the urge will pass, the stool will sit in the bowel and get larger, harder, and drier. Many children with constipation may be fearful and hold back on the urge to have a bowel movement (BM). It is important to teach your child to listen to your body or listen to your bottom and go to the toilet when they get the message. Sometimes a warm bath, active playtime or tummy massage will help move the bowels. Children who are toilet trained should practice sitting on the toilet for 5-10 minutes every day after each mealtime. This is very important to their success. 7

8 Listening/Watching for signs When children try to stop the urge to have a bowel movement they may: suddenly stop whatever activity they are doing hide or leave the room stiffen up, extend their bodies upright, stand on their tip toes and tighten the muscles in their bottom suddenly squat or sit down make a face or change the tone of their voice begin to sweat or become pale not be able to pay attention to you Ask your child what message is your body/bottom giving you? and take them to the bathroom. 8

9 DAILY BOWEL DIARY It helps to keep a record of your child s medication and bowel movements. Date Medication Sat on Toilet BM size & Consistency Soiling accidents 9

10 Nutrition It is important that your child eat a healthy diet. Following Canada s Food Guide, including fruits and vegetables and some whole grains, is a good way to ensure your child is eating well. Tips: routine meal times help with routine toileting; don t skip meals or snacks offer water often. Avoid too much milk, juice or pop Extra fiber will help your child s bowel habits, but not until the constipation is resolved. Canada s Food Guide If you need help with your child's diet, ask your doctor or Nurse Practitioner for a referral to a dietitian, if possible one who specializes in pediatric nutrition. For free nutrition information you can call and ask to speak to the Pediatric Dietitian at Healthlink BC. Here are some helpful websites:

11 Medications Medications are often very helpful to get into a comfortable routine with toileting. The goal is a daily bowel movement with no soiling. Medications should only be prescribed by a doctor or Nurse Practitioner. Do not use food or fibre to treat constipation unless advised by your doctor. Often parents worry that their child s body will get used to the medications (laxatives) and not have a natural urge to go or that the medications may drain the body of other important nutrients. When used correctly, this will not happen. Give medication at the same time each day. Often the medication can be mixed in a drink such as juice. You need to know the safe range or dosage for your child s medication(s) so that you can adjust them as needed. Don t wait until the next appointment to find a dose that works. The first step in treating constipation is to empty the large intestine (bowel). These methods are commonly used to do this: enemas push fluid into the rectum, causing the urge to have a bowel movement Get to one a day! One comfortable bowel movement every day. suppositories irritate the bowel, causing it to push out a bowel movement laxatives flush out the lower bowel disimpaction sometimes a nurse or doctor need to manually help very large and hard stools to come out 11

12 Keeping Bowel Movements Regular Daily laxatives help constipated children have soft, pain free bowel movements. Medication for Constipation Your doctor may prescribe one or more of these treatments to produce soft, painless bowel movements. To keep bowel movements regular, your child may need to take the medication for a period of time. There are three main types of medications (laxatives): Water retaining Stimulant Lubricant Water Retaining Laxatives These are the most commonly used laxatives for childhood constipation. They help keep water in the stool so it is softer and easier to pass. Some of these include: Polyethylene glycol (PEG) 3350 (Lax-A-Day) Lactulose Milk of Magnesia Stimulant Laxatives These medications speed up the passage of stool by irritating the lining of the intestines: Senokot Dulcolax Fletcher s Castoria Ex-Lax Lubricant Laxatives This medication helps bowel movements by coating the stool with a water proof film, keeping it soft and easy to pass. Lubricant laxatives may cause some staining in your child s underwear: Mineral Oil (Lansoyl ) 12

13 Prebiotics such as inulin (Benefibre, Metamucil and Simply Clear ) help healthy bacteria to grow in the gastrointestinal tract which adds soft bulk to stools. Probiotics are the actual healthy bacteria cultures. Both are still under study for use in children and should not be used if your child has an immune deficiency disorder. Consult with a doctor before using prebiotics or probiotics. Bulk Forming Agents such as Psyllium fibre Metamucil, Citrucel, Fibercon, and Fiberall are fibre-based medications that dissolve or swell in the intestines, lubricate and soften the stool, and make the passage of bowel movements easier and more frequent. Stool Softners Are laxatives that prevent hardening of the stool by adding moisture. Colace You need to understand that treating constipation is often a long journey. The symptoms may take many months to resolve. The medication routine you have set up for your child may suddenly stop working and need to be reassessed. It has been described as a game of snakes and ladders! Eventually you will win the game but not without many ups and downs. Although many healthy children do not have a BM everyday, the goals for a constipated child are to use medication to help him or her to have a regular daily bowel movement without discomfort, and to stop soiling in his or her underpants. 13

14 Activity If a child is constipated he or she may have little energy and may not want to play or be active. However, daily activity is important to help move food through the bowel. Using back, stomach and leg muscles helps intestinal health. Keep in mind that being active helps the bowels move, so be prepared! It is a good idea to take a bag of moist wipes, clean underwear and any other items you may need when you are away from the house. School As with any health condition, it is important that your child s teacher be informed about your child s constipation. Your child may need a safety net. This may mean using a secret code which tells the teacher that he or she needs to go to the bathroom. Your child should NEVER have to wait. Some children need privacy, such as a single stall bathroom where nobody else will come in. Your child will need to know where all the bathrooms are in the school, so that he or she will not panic trying to find one. Clothing should be easy to remove. Depending on the severity of your child s constipation/or soiling, it may be necessary to keep a change of clothes at the school. Children with encopresis or soiling are likely to be teased or bullied due to odor. Talk to your child s teacher, family members and siblings about this, to prevent your child from being bullied. 14

15 8 Tips for Parenting Your Child with Constipation Constipation is a digestive problem, NOT an emotional problem. Children do not withhold bowel movements or soil themselves to cause trouble or rebel. However, many children with constipation show behavior that can be very frustrating to deal with. You are not alone. Here are a few suggestions: 1. Look after your child s self esteem. Praise him or her for accomplishments no matter how small; for example, taking medication when asked or sitting on the toilet after meals. 2. Set limits and be consistent. Set rules that will help your child understand what they need to do to overcome their constipation. This includes taking medication, eating healthy, drinking enough fluid, listening to the message their body is sending, and taking time to sit on the toilet every day. Sometimes a simple reward chart will help. Keep the rewards simple. A trip to the park, a bike ride together, a small toy, etc. 3. Make time for toileting. Make sure your daily routine has time for your child to sit on the toilet without feeling rushed. This may mean both of you getting up 10 minutes earlier in the morning, or planning dinner time and evening activities with time in between to sit on the toilet. Your child should only sit on the toilet for 5-10 minutes. Depending on your child s age, it may be unrealistic to expect him/her to sit alone. Sit with your child in the bathroom, have a chat or read a book. Help them feel clean after toileting. Keep some moist wipes handy when away from home. 15

16 4. Be a good role model. Let your child know when your body is sending you a message to have a bowel movement. Let them know you are going to the bathroom right away. 5. Be flexible and willing to adjust your parenting style. Although keeping a routine is important, a little flexibility goes a long way. 6. Make communication a priority. If your child is old enough, talk with them regularly about how he/she is progressing and how medications, healthy eating, and active play are helping (in simple terms). The more your child understands, the easier it will be to have their co-operation. Allow your child to express feelings; there may be days when he/she feels down or frustrated 7. Show that your love is unconditional. Never punish or tease your child for soiling or for not having a bowel movement. Try not to be frustrated when their toileting needs interrupt your plans for the day. Having a bowel movement is important for their comfort and health. It is not important for your love or pride. Your child needs to know you love and support him/her regardless of their success. This same message needs to come from all family members and care providers. 8. Be aware of your own needs and limits. Dealing with your child's constipation can be both frustrating and embarrassing. Everyone has bowel movements and everyone has struggles from time to time. Talk openly with family, friends and health care professionals. Share what you and your child are going through. It is important to have their support and understanding. 16

17 Pulling it all together Supporting your child to have regular bowel movements requires: daily routine healthy nutrition medications daily activity supportive parenting Be patient with time, it will be resolved. Abdomen: Tummy Anus: Outer opening of the rectum (bottom) Bowel Movement (BM): Passage of stool (poop) from the rectum (bottom) Large Intestine: See page 6 GLOSSARY OF TERMS Laxative: Medications taken to encourage bowel movements and relieve constipation Pediatric: Concerning the treatment of children Rectum: See page 6 Small Intestine: See page 6 Stomach: See page 6 17

18 RESOURCES FOR PARENTS Informational Websites KidsHealth many health related topics including constipation, toilet training, parenting, etc. University of Virginia, School of Medicine clinical-services/tutorials/constipation Interior Health Authority Other resources Your local Health Unit Public Health Nurse Books How To Get Your Kid To Eat...But Not Too Much by Ellyn Satter, 1987, Bull Publishing Company ISBN Child of Mine : Feeding with Love and Good Sense Ellyn Satter, 2000, Bull Publishing Company, ISBN BC Healthlink Dial Talk to a Nurse 24 hours/day, 7 days/week Pharmacist available between 5 p.m. - 9 a.m. daily Dietitian between 9 a.m. - 5 p.m. - Monday to Friday 18

19 REFERENCES *Constipation in Infants and Children: Evaluation and Treatment, A Medical Position Statement of the North Amer. Society for Pediatric Gastroenterology & Nutrition. JPedGastrNut, 29(5): , 1999 Chronic Constipation and Encopresis in Children available at

20 Comments /Feedback Please send any comments or feedback regarding this information booklet to : Interior Health Authority Nutrition.earlyyears@interiorhealth.ca Reorder #