Severe Chronic Constipated Is Very Difficult To Manage
Question: Our four-year-old son has severe constipation for more than two years. We cannot recall exactly how the problem started, although I vaguely remember that it might have started when we tried to toilet-train him. We have seen many doctors and have tried all kinds of stool softeners, mineral oil, and laxatives, but nothing seems to work. In the last few months, he stopped having any bowel movement altogether. Every day he has some greenish liquid stool seeping into his underwear almost continuously. I try to clean him as often as I can, I go to his daycare and get up several times a night to remove this slimy stool. He is getting very sore around his anus. When I sit him at the toilet, he just cannot have a bowel movement. Frankly, I am frustrated and depressed over the whole ordeal. Please give me some advice.
It sounds like your son has very severe constipation that has been going on for a long time. I am not surprised that you cannot remember how the problem started. However, in my experience after seeing many children with severe constipation, the vast majority of them started after their parents attempted toilet-training when they were not quite ready yet.
There is no accurate statistics to tell how frequent constipation happens in children. However, it is not uncommon for parents to tell me that this problem also happens on one or both sides of the family.
Children with constipation have infrequent bowel movements that are too large for their age and size. A one-year-old child’s normal bowel movement is much smaller in size than that of an adult. The frequency of bowel movement varies from person to person. Having a bowel movement every second day in one child can be just as normal as another child who has two or three bowel movements a day.
It is important for parents to pay attention to the change of frequency of bowel movement in their child. If a toddler normally has one or two soft stools a day, then changing to one bowel movement every second day when the parents start to toilet train him, this can be a sign of early constipation that may gradually gets worse over time.
Parents should also pay attention to the size and consistency of the stool. A young child should not have stool that resembles that of an adult. Stool moves through the large intestine, and finally reaches the rectum where it stays until a bowel movement. The size of the rectum is much smaller in a child compared with an adult. Therefore stools that are large in size is indicative of constipated stool.
When stool reaches the rectum, it stays there for varying periods of time, until the child has the urge to have the bowel movement. When stool stays in the rectum, the water in the stool is gradually absorbed into the body, making the stool firm and then hard. Therefore, hard stool generally indicates presence of constipation.
In your family’s situation, your son likely has a piece of large and hard stool stuck in his rectum and the adjacent colon, which is just too big for him to push out, and this stool could have been there for a fairly long time. When you try to help him by using stool softeners and laxatives, the stool from above just get around this large piece of impacted stool, and leak out of the anus into his underwear. Because of this impaction, he can no longer have normal bowel movement, not even the large constipated stool. He has virtually no control of this smelly, leaky problem.
Your son needs urgent treatment to dislodge this large mass of impacted stool and to stop the leaking. This seepage of stool is very humiliating for any person. Very soon, other children will recognize his problem, and he can be teased and isolated. This can create long term psychological problem for him.
The first thing that you and your doctor need to do is to break up this piece of constipated stool. Since you have tried laxatives for a long time, just giving him more is not going to work. Putting enema into his rectum cannot completely remove a large impacted stool. There is, however, a solution that contains polyethylene glycol and electrolytes, which is effective in dissolving hard constipated stool. Unfortunately, the amount that is required to do the job is usually too much for children to drink. Not infrequently, doctors have to put a plastic tube through a child’s nose into the stomach, and instill this solution over hours or even day. The most important thing is to completely clean out the impacted stool; otherwise, constipated stool can build up very quickly in the now empty, but much distended rectum.
Once your son is free from impacted stool, he needs a combination of stool softener, fiber, and even mild laxative, to maintain regular bowel movement. The goal is to have at least one (but can be more) bowel movement a day that is soft and pasty. This may sound like a lofty goal, since he has had no real bowel movement for so long, but it can be achieved over time. Your doctor will have to adjust the amount of medicine very frequently with you, in order to make sure that he has regular bowel movements as mentioned above, but not to the point of diarrhea every day.
Your son also needs to develop what we call a regular bowel habit, which means that he can initiate a bowel movement daily at around the same time. He needs to sit at the toilet at least once or twice a day, to try to have a bowel movement. The best time is shortly after a meal, a time when the intestines are most active. If he doesn’t like to sit at the toilet, you can try him at the potty, or use a toilet-seat insert, so that he feels more secure. You should also place a footstool in front of the toilet, so that his feet can reach solid ground to help him to push out the stool.
You may also want to reduce the amount of dairy product that he eats. It is known that the fat content in dairy products can reduce the motility of the intestines.
It is going to take many months for your son to completely recover from this ordeal. However, it doesn’t mean that he will have to suffer the whole time while he is recovering. It means that you have to be vigilant, and watch his bowel movement, both the frequency, as well as size and consistency of the stool. With careful monitoring and adjustment of medication, your son can be completely free of this problem when he grows up.
Finally, I want to emphasize the importance of eating fruits and vegetables. Both of them are good sources of natural fibers that can help to regulate our bowel. They also provide much needed vitamins to keep our body healthy.
I hope this information can help you and your doctor in dealing with your son’s constipation.
[Note to Readers: Please read other more recent columns on constipation. We are using PEG with more success to manage mild and moderate constipation. Severe constipation like this child still needs more complicated management.]