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Nutritional management of constipation in children

Toddler potty training. reading books on the toilet.

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Constipation occurs when stools become hardened and difficult to pass. As with adults, the frequency of children’s bowel movements varies from child to child. There are many “normal” patterns for bowel movements in children.

Sometimes children’s faces turn red and they appear to strain to pass a stool, but if the stool is soft and the child has no other problems, this is not a concern. Most children will occasionally become constipated. Usually this is only a short-term problem requiring home treatment. However, some children are frequently constipated (chronic constipation).

Acute (sudden) constipation: Can be caused by disruptive circumstances such as travelling that upset the diet, and time and place of defecation. Also causing acute constipation is a lack of exercise, certain medication as well as pain caused by haemorrhoids and anal fissures.

Chronic constipation: The cause of chronic constipation cannot always be identified, but the most significant factor appears to be the painful passing of a stool once constipation has already developed. The longer a bowel movement is resisted the larger and harder the stool becomes, which may cause pain when it is passed. Children in particular may then withhold stools, which cause cramping.

After some time the child may be unable to resist the urge to have a bowel movement and will pass a large mass of faeces. This can be painful, as the child may have to "push hard" during the bowel movement.

Passing the stool relieves the pressure until another mass of stool collects and the cycle repeats itself. More seriously diseases of the nervous system, such as Hirschsprung's disease or diseases affecting the whole nervous system such as spinal cord damage can worsten constipation. Diseases which affect the nervous system will not respond to the usual treatment for constipation and it must be dealt with by specialists in these fields.

Symptoms of constipation

– Constipation may occur with cramping and pain in the rectum from the strain of trying to pass dry, hardened stools. Some bloating and nausea may occur.
– Sometimes small amounts of bright red blood appear on the stool. This can be the result of anal fissures – slight tearing of the anal membrane as the stool is pushed through the anus – which make the passing of stools very painful. The fissures, which often appear when constipation is chronic, should heal when the constipation is controlled.
– Appetite may be suppressed. There may be decreased interest in usual activities.
– Urination may be more frequent because of pressure on the bladder. In the case of chronic constipation, there may be involuntary release of urine (incontinence).
– Occasionally, particularly when constipation is chronic, a stool becomes lodged in the rectum (impacted), with mucus and fluid leaking out around the stool. This can be experienced as constipation alternating with liquid diarrhoea. In rare cases, uncontrollable leakage of liquid or loose faecal material (faecal incontinence) occurs and underwear gets soiled. This is called encopresis when it occurs in a child who is past the age of normal toilet training. Some children, out of embarrassment, might hide or throw away underwear.

Dietary treatment of constipation

1. Provide regular meals

A child should not skip a meal. A good eating pattern is to have 3 meals daily with a small snack in-between meals. This will also prevent overeating after a meal has been skipped.

2. Provide healthy, balanced meals

Items from each food group should be included daily. Use the plate model as a guideline for serving sizes.

  • Body building foods: Fish, chicken, beef, pork, egg, dried beans, lentils
  • Dairy products: Low fat milk, yoghurt, cheese, lite custard and ice cream.
  • Energy foods: Cereal, porridge, bread, rice, pasta, potatoes, sweet potatoes, samp, mielierice etc.
  • Protective foods: Fruits and vegetables.

3. More fibre-rich foods

  • Soluble fibre forms a gel in the gastric intestinal tract. Good sources are oats, oatbran, apple, banana, citrus fruit, carrots, barley, rye and dried legumes.
  • Insoluble fibre is roughage and attracts water to make stools softer. Good sources are pips, seeds and skin of fruit and vegetables as well as whole-wheat products and digestive bran. Include both of these fibres to ensure a soft stool and improved movement through the gastric intestinal tract.

How to include fibre into your child’s diet:

  • Start with a whole-wheat or high fibre breakfast cereal in the mornings like Oats, All bran, Weetbix, Muesli, Hi Fibre bran, Wholewheat Pronutro.
  • Give a fresh fruit like apples, bananas, oranges, pears, peaches as snacks in between meals.
  • Give dried fruit like raisins, prunes, dried peaches and pears, mango and apple rings as snacks in between meals.
  • When having a dessert make a fresh fruit salad or stewed fruit with ice-cream or custard.
  • Add whole grain starches like samp, mielierice, barley, brown rice, whole wheat pasta, baby potatoes with the skin, to the main meals.
  • Make sandwiches with wholewheat bread, seedloaf.
  • Use popcorn and whole wheat crackers like Provita, Ryvita, Wheatsworth as snacks.
  • Add dried beans, split peas, beans and barley to curries, stews and soups.
  • Digestive Bran may be added to your diet to increase the total intake of fibre. Start with 1 teaspoon per day and gradually increase the intake to 3 to 4 teaspoons a day. Bran can be added to porridge, cereals, soup, sauces, yoghurt, mince meat dishes and stews.

4. More Water and Fluid!

Roughly children should have a ½ to 1 cup of fluid every 3 to 4 hours. To calculate your child’s fluid requirements: Children aged 1-3 years require 95mL/kg, 4-6 years require 85mL/kg and 7-10 years require 75mL/kg. Give mainly plain clean water and low fat milk. Rooibos tea and diluted 100% fruit juice can also be given daily. Warm water with breakfast may stimulate bowel movement and prune juice is a natural laxative and may be taken as part of the fluid intake during the day. Avoid carbonated cold drinks like Coke, Cream soda and Sprite. Also avoid coloured and sweetened drinks like Oros.

5. Less fat and sugar

  • Avoid fatty and fried foods like chips, crisps, vetkoek, doughnuts etc.
  • Avoid trans fats found in commercially baked products like cookies, biscuits, cakes etc.
  • Especially avoid saturated fats which are found mainly in animal products:
    • Remove all visible fat of the meat; Choose extra lean mince/ meat;
    • Remove skin from the chicken;
    • Rather grill fish and do not fry in oil;
    • Use low fat milk products and choose low fat cheese ie Melrose and laughing cow’s cheese wedges, slices and spread.
  • Use healthy food preparation methods ie. Steam, Boil, Grill, Bake in oven without fat; instead of frying foods in fat/ oil. Use non-stick spray and a pan that doesn’t stick when frying.
  • Use unsaturated fats found mostly in plants like soft margarine, olive and canola oil, sunflower and grapeseed oil as well as olives, avocado pear and nuts and peanut butter.
  • Do not add extra sugar to your child’s food. Limit sweets and chocolates to special occasions.

6. Visit the toilet regularly

Set aside relaxed times for having bowel movements. As urges usually occur after mealtimes, it may help to ask a constipated child to sit on the toilet after meals, especially breakfast. It may help to make this a daily routine.

Teach them to defecate when they feel the urge. When a stool needs to pass the bowel send signals to the brain; If ignored, the urge will go away and the faeces will eventually become dry and difficult to pass. A firm footing, perhaps with the aid of a footstool, helps children position themselves properly on the toilet.

7. Be active!

Physical activity stimulates bowel movement and therefore also the movement of the stool. Children should play around and be active for at least 60 minutes every day.

8. Medication

Your doctor may recommend a laxative or stool softener if improvements in diet and toilet habits do not ease the constipation.
Laxatives work by irritating the lining of the bowel, which speeds up the passage of faeces. Regular use of laxatives is not recommended, as it decreases tone and sensation in the large bowel, causing laxative dependence. Do not give laxatives or enemas to your child without talking to your health professional first. Children should not need an enema or a laxative to have a bowel movement.

Bulking agents such as bran and psyllium are not laxatives, but work by increasing the volume of stool and making it easier to pass. Bran & psyllium are safe to use and regular use renders them more effective. Always drink plenty of water when taking bulking agents.

Warning signs!

When to see your doctor:

  • New constipation that persists or other bowel habit changes that continue after one week of home treatment.
  • Rectal pain that develops, increases, or lasts longer than one week.
  • Development or increase of abdominal pain.
  • Increase of blood in the stool or appearance of blood for longer than one week.
  • Increased severity or frequency of symptoms.
  • Uncontrolled leakage of faeces.

Do not be discouraged!

Parents should not be discouraged if the constipation recurs during these months. As the rectum is a muscle, it becomes stretched in chronic constipation and might require several months to return to normal. If your child suffers from encopresis, a clinical child psychologist may be of benefit to see. Possible underlying psychological problems can be treated with child psychotherapy.

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