INFANTILE CONSTIPATION

Constipation is a common problem in infants and children and it troubles both our little ones and parents, who are concerned. There are three periods in a child’s life when they are prone to developing functional constipation. The first is during the introduction of cereals and solid foods into the infant’s diet, at about 6 months. The second is when toilet training begins, at 18-24 months. The third is when the child starts school. In all three of these cases, significant changes in the child’s diet and daily routine occur that either subconsciously or consciously lead to constipation. Approximately 30% of children aged 0-4 years show signs of constipation.

What is childhood constipation?

Parents should be aware that the frequency and quality of stools normally vary with age and diet. In non-breastfed infants the stools are about 2-3 per day, while in breastfed infants they range from one after each meal to one every week. Above the age of 4 years normal stools range from 3 per day to 3 per week, as long as they are not hard. Empirically, parents infer constipation if they see delay in defecation or difficulty causing discomfort in the child.

However, a prerequisite for making a diagnosis of constipation is the recognition of normal bowel function and its variations by age.

Physiology of the gut

To understand what constipation is, we first need to see what role the large intestine plays.

The process of digestion

1. 1. 1. The food enters the stomach, where it is masticated and dissolves in the acidic environment, gradually creating a porridge
      2. The porridge travels to the small intestine where the nutrients are absorbed
      3. The porridge enters the large intestine, now poor in nutrients, and slightly dehydrated
      4. As they travel through the large intestine, the products of digestion lose moisture and take shape. At the same time, the indigestible substances that now make up these products feed the intestinal microbiome, which is most numerous in the last part of the large intestine
      5. The stool, now formed, remains in the rectum until enough is collected to make defecation imperative

The large intestine is the part of the intestine where fluids and electrolytes are absorbed and stools are stored before defecation. Normal defecation is controlled by the anatomical muscle complex of the pelvis which forms two sphincters that surround the anus. The medial sphincter is permanently in tonic contraction, while the external sphincter is in relaxation when the rectum is empty of faeces. When stool enters the lumen of the rectum, voltage receptors located in the wall activate nerve cells resulting in relaxation of the medial sphincter. The stool is propelled into the lower part of the rectum whereupon the urge to defecate is created. This increases intra-abdominal pressure, the external sphincter relaxes and stool elimination begins. The defecation function can be deliberately inhibited by contraction of the external sphincter and gluteal muscles resulting in a backward pushing of the stool. If the refusal to defecate is repeated several times this leads to distension of the rectum and eventually to a sequential decrease in rectal and colonic muscle tone and stool retention.

Organic childhood constipation

In 95% of cases, evidence suggests that childhood constipation is functional (idiopathic), i.e. not due to an underlying organic damage. The main causes of organic constipation are:

• • • Anatomical abnormalities
    • Neuromuscular diseases of the intestine
    • Neurological causes
    • Systemic diseases
    • Intolerances
    • Drug use

Functional constipation in children

Neonates and young infants with functional constipation have difficulty coordinating the increase in intra-abdominal pressure with the relaxation of the pelvic musculature. This subsides over time. Later in the second infancy and early childhood, painful defecation from hard stools can cause further inhibition, stool retention and the establishment of constipation. This mainly occurs in the transitional stages of feeding i.e. from breast milk to first infant milk or immediately after the start of solid foods. Finally, in older children, deliberate faecal retention is the main mechanism of constipation. Painful defecation or fear of the toilet triggers the onset of constipation , which has two peaks in time, the toilet learning period and the beginning of school age. Stool retention leads to restlessness, abdominal pain or distension, irritability and anorexia, as well as diarrhoea from overfilling and incontinence.

Functional constipation in children over 4 years of age is diagnosed according to the Rome IV criteria if there is no suspected organic cause and irritable bowel syndrome (IBS). The doctor will consider whether in a 4-week period the child has two or more of the following:

• • • Less than 2 stools per week
    • At least one incident of incontinence per week
    • History of deliberate postponement of defecation
    • History of painful or hard stools
    • Large mass of faeces
    • Large calibre stools

Diet plays an important role in the development of constipation. In particular, reduced fibre intake has a negative correlation with the occurrence and severity of constipation. In addition to a poor diet, constipation is also caused by poor toilet habits, i.e. when a child postpones defecation, resulting in stool remaining in the bowel for a long time. The psychology of the child when going to the toilet is important: if he considers the toilet to be an unpleasant experience, intertwined with failure to defecate and frustration, constipation may even settle in the absence of organic reasons or poor nutrition.