Any definition of constipation is relative and depends on stool consistency, stool frequency and difficulty in passing stool. A child may have soft stools only every 2nd and 3rd day without difficulty. This is not constipation. Normal bowel frequency varies widely. The average baby passes three to six stools per day in the neonatal period. One to two stools per day at 1 year of life and approximately one stool per day or every other day in the preschool years. Thus, constipation can be defined as a delay or difficulty in defecation that has been present for 2 weeks or longer.
Constipation may be functional (non-organic) or organic:
- Intestinal: Hirschprung disease, anal stenosis, anal fissure, ectopic anus, fistula- in -ano
- Endocrine: Hypothyrodism, panhypopituitarism
- Neuromuscular: Cerebral palsy, mental retardation, spinal cord lesions, myotonic dystrophy.
- Drugs: Narcotics, Vincristine
- Dietary: Poor intake of fluids, low fibre diet , excessive intake of proteins and fat
- Poor bowel habits: Suppression of urge to defecate.
EVALUATION OF CONSTIPATION
What to ask?
- Is constipation present since birth or has developed later?
- Type of stool
- Dietary history
- Pain associated with defecation
- History of drug intake
- History of passing blood in stools
- History of faecal incontinence
- History of vomiting
- History of prolonged jaundice, feeding difficulty in neonatal period
- Occupation of parents
- Developmental history.
Is Constipation Present Since Birth?
The commonest cause of organic constipation with onset usually in the neonatal period is congenital aganglionic megacolon. It presents at birth with delayed passage of meconium, which may be relieved. The infant is then brougnt again for difficulty in passing stools. Three important organic causes of constipation since birth are congenital megacolon, anal stenosis and hypothyroidism. Functional constipation typically starts after the neonatal period, usually in a child older than 18 months.
Type of Stools
Stools of breastfed baby are golden yellow and loose in consistency, which is due to increased lactose content of human milk. The stools of a baby who is receiving top milk or formula milk are pale and firm in consistency. They tend to be constipated. The stools of an infant with congenital megacolon are pellet or ribbon like.
A detailed dietary history must be taken. Improper diet is an important cause of constipation in toddlers and older children. Inadequate intake of fluids, cereals, vegetables and fruits, i.e. food with low fiber content can lead to constipation. Also, excessive consumption of food stuffs rich in protein and fat can also result in constipation.
Enquire about the bowel habits. Does the child avoid going the toilet? Toddlers are often too involved in their play and avoid going to the toilet. In older children it is usually due to lack of time in the morning to go to the toilet due to hurry to go to school or inadequate facilities in school.
Is There Pain Associated with Defecation? Pain in the perianal region would suggest anal fissure or an inflammatory lesion in the perianal region. Any painful condition of the anorectal region can lead to constipation. Because of fear of pain, the child withholds the stool leading to further absorption of fluid from the gut and hardening of stool. Anal fissure can therefore be both cause and result of constipation.
History of Drug Intake- Certain drugs are known to produce constipation
History of Passing Blood in Stools- Presence of a streak of blood on the surface of a hard stool is often seen in anal fissure.
History of Encoporesis – In cases of severe constipation history of encoporesis may be present. This is overflow soiling caused by passage of fluid stool.
History of Neonatal Jaundice and Feeding Difficulty -In a child with cretinism there would be a history of feeding difficulty and prolongation of jaundice in the neonatal period.
History of Vomiting – In cases of pyloric stenosis there is a history of projectile vomiting from 2nd or 3rd week of life associated with constipation.
Occupation of Parents –In a child with chronic constipation one must enquire about the occupation of parents, especially if it involves exposure to lead.
Developmental History- Global developmental delay is an important feature of hypothyroidism also seen mostly in children with mental retardation
What to look for?
- Assessment of growth
- Presence of anemia
- Look for lead line
- Signs of hypothyroidism
- Examination of perineum and back
- Examination of abdomen
Assessment of Growth
Failure to thrive in a child would indicate an organic cause of constipation, e.g. in cases of congenital megacolon and pyloric stenosis.
Anemia -One must look for the presence of anemia. Iron deficiency anemia is often observed in a child receiving mainly milk diet. Such a child would often be brought to the physician for constipation. His weight and height for age would be normal. Anemia would also be present in a child with long-standing constipation, especially due to congenital megacolon. Children with chronic lead intoxication would also have anemia.
Signs of Hypothyroidism
Look carefully for signs of hypothyroidism viz. open fontanelle, dry skin, coarse features and short stature.
Examination of Perineum and Back – One must look for an ectopic anus, anal fissure, proctitis andback for meningomyelocele.
Examination of Abdomen
Distended abdomen would be seen in congenital megacolon in cases of hypothyroid. Wrinkled abdominal wall in cases of Prune-Belly syndrome. Palpation of the abdomen may reveal fecaliths or a fecal mass in the lower abdomen. Investigations are seldom required in children with constipation. A good history and clinical examination helps in arriving at a diagnosis in the majority of the cases. However, in some situations, investigations are needed.
Which investigations to be done?
- Estimation of thiodothyronine (T3) thyroxine (T4), Thyroid stimulating hormone (TSH)
- Barium enema
- Rectal manometry
- Rectal biopsy
- Magnetic resonance imaging of spine.
It is useful in delicate children, products of artificial baby foods. Abnormal craving for coarse food, chalk, charcoal, dry food, clean white rags, tea or coffee grounds, fruits vegetables, dry rice and indigestible things. Aversion to potatoes, to meat, which disagrees. Constipation for many days, with soft stool. No urging, have to aid with fingers. Rectum seems paralyzed. Perspiration from straining at stool. Inactive rectum, even a soft stool is passed with difficulty, hard stools cause severe cutting. Can only pass stool when standing. Rectum seems paralyzed.
Opium contains about eighteen alkaloids, of which Apomorphine, Morphine and Codeine are well known. Incarcerated umbilical or inguinal hernia. Obstinate constipation. Stools of hard black balls. Bloody mucus oozes from open anus. Retention of stools from ileus. Stools involuntary; after fright. Violent pain in rectum as if pressed asunder. Difficult emission of flatus. Intestinal spasms, child cries day and night. Stool insufficient. Stool remains long in the rectum with no urging.
Children ask for things that are difficult to find, immediately throw it away (cham). Mucous membranes become dry, hence discharges are scanty and adherent. Dryness everywhere, of mouth, throat etc. Thirst, for large quantity of cold water; also for warm drinks which amel. Stools; large dry, very hard, as if burnt; loose, painless, undigested, involuntary, during sleep. Burning in anus, with stools.
A mental condition arising from lack of love, affection and recognition, especially in childhood. Rejected children, orphans. A liver remedy with pronounced characteristic constipation. Especially adapted to children who cannot digest milk. Constipation of infants during dentition; only passing small quantity; stools knotty, like sheep’s dung, crumbling at verge of anus. Painful smarting hemorrhoids. Constipation with liver affections; stools like sheep dung, crumbling at verge of anus.
Inactive intestinal canal. Ineffectual urging. Stool hard, difficult, small, incomplete. Haemorrhoids, very painful to touch, aching (Mur ac). Rubbing the abdomen or drinking something warm may help to relieve the symptoms. A craving for sweets and an energy slump in late afternoon and early evening are strong indications for Lycopodium.
When this remedy is indicated, the person strains for long periods without success. People who need this remedy are nervous and mentally acute, but also chilly, physically frail, and easily fatigued. Stool comes down with difficulty; when partly expelled, recedes again. Great straining; rectum stings; closes upon stool. Feces remain a long time in rectum. A “bashful” stool begins to come out, but eventually retreats.
“Wants to but can’t” is a phrase that brings Nux vomica to mind. This remedy is often helpful to people who are impatient, tense, and ambitious—who work too hard and exercise too little, indulge in stimulants or alcohol, and are partial to sweets and spicy food. Headaches, chilliness, and constricting pains in the bowels or rectal area often accompany constipation when Nux vomica is needed. Constipation, with frequent ineffectual urging, incomplete and unsatisfactory; feeling as if part remained unexpelled. Constriction of rectum. Irregular, peristaltic action; hence frequent ineffectual desire, or passing but small quantities at each attempt. Absence of all desire for defecation is a contra-indication.
People who need this remedy often feel more stable when constipated, and experience discomfort and fatigue when the bowels have moved. Large stools are hard at first, then sticky, then liquid. The person may feel chilly and sluggish, have clammy hands and feet, crave sweets, and feel weak and anxious when ill or overworked. Crawling and constriction in rectum. Stool large and hard (Bry); whitish, watery, sour. Prolapse ani, and burning, stinging haemorrhoids. Diarrhoea of undigested, food, fetid. Ravenous appetite. Children’s diarrhoea. Constipation; stool at first hard, then pasty, then liquid.
Constipation is a common symptom in toddlers and children. However, one must appreciate normal variation in frequency and consistency before starting treatment. The commonest cause for constipation is dietetic. Insufficient intake of water, food and fluids and a diet rich in proteins causes constipation. Also babies whose diet is exclusively milk and whose weaning on semisolid feeds are delayed have constipation.
Other common causes are neglect of bowel training and painful conditions, in the anorectal region. After excluding non-organic causes, one should proceed to identify an organic cause such as congenital aganglionic megacolon. The role of homoeopathic treatment indicates that childhood constipation can be treated completely by homoeopathic medicines, with no complications and given a healthy life.
- Italian Journal of Paediatrics: [Constipation in Children, Nadeem A Afzal]
- Synthesis Repertory
- Homoeopathic Materia Medica, William Boericke .M.D
- Manuel of Paediatric Differential Diagnosis