Plugged up: Doctors see signs of worsening constipation in children

This month, Hopkins Children's is opening a multidisciplinary clinic to meet these children's need for medical and behavioral therapy.

And while the doctors have not quantified the precise increase in the number of patients, they see children with constipation daily and saw a 30-percent jump in related visits between 2008 and 2009.

Hopkins Children's physicians say it's unclear whether the increase they are seeing signals a true rise in severe cases or if it stems from delayed diagnosis, insufficient treatment and referral at more advanced stages.

"The reality is that too many children are either not treated at all, start treatment too late or are treated inadequately, leading to persistent, severe and chronic constipation," says Maria Oliva-Hemker, M.D., director of pediatric Gastroenterology & Nutrition at Hopkins Children's.

Oliva-Hemker says that the condition is easy to miss in young children, and its severity is often overlooked, which results in delayed treatment and worsening symptoms. Half-truths and full-blown myths are partly to blame including the notions that constipation usually goes away on its own, the child will outgrow it or that a change in diet alone is enough to restore normal bowel movement.

"Severe constipation needs to be treated early and aggressively," Oliva-Hemker says. "And no amount of fiber or prune juice will help a child with serious chronic constipation."

Oliva-Hemker says most children have functional constipation, meaning that it's not caused by a disease or an anatomic anomaly, and is defined as having fewer than three bowel movements a week for three, not necessarily consecutive, months in a year.

Signs that should prompt a visit to the doctor's office include abdominal bloating and a feeling of fullness, straining with bowel movements, lumpy or hard stools and/or small pellet-like stools, accompanied by a sensation of incomplete emptying of the bowel. Children may also refuse to go to the toilet or hide to go in a private place, or they may experiences underwear soiling and bedwetting, both complications of serious constipation.

Constipation develops insidiously over time, Oliva-Hemker says, and usually begins when a child starts to hold back bowel movements. Holding the stool gradually disrupts the brain-colon signaling mechanism that tells a child when stool needs to come out, and stool builds up in the colon, stretching it beyond its normal shape and size. The longer the stool stays in the colon, the harder and larger it gets, making bowel movements painful.

Toilet training and the start of a new school year are high-risk periods that can trigger episodes, she notes. School-age children may not want to use the school bathrooms or may not be allowed to use them except during lunch or school recess. Other contributors include travel, camping, viral illness and dietary changes.

Research shows children with chronic constipation have a worse quality of life than those with more serious medical conditions like inflammatory bowel disease and gastro-esophageal reflux disease, says Hopkins Children's behavioral therapist Tara Mathews, Ph.D., and the dangers of untreated constipation extend beyond quality of life.

A recent European study published in the journal Pediatrics showed that 25 percent of children with the condition continue to have symptoms as adults. Oliva-Hemker believes the numbers in the United States may be similar, if not worse.

"There is a subset of the population suffering from this benign, yet often debilitating condition that is often under-treated and only gets worse over time," Oliva-Hemker says. And, she adds, as more children with constipation grow into adults with constipation, their condition may worsen increasing their use of medical testing and treatment over time.

The first line of treatment for chronic constipation should be over-the-counter osmotic products like polyethylene glycol-electrolytes, sold in powder form. They work by increasing the amount of water in the colon to promote bowel movement. These products are not laxatives and are not habit forming, gastroenterologists say, but need to be taken regularly, and the dose needs to be monitored and adjusted as needed. Children with serious constipation should start treatment with a thorough colon cleanse before switching to maintenance therapy.

To prevent constipation, parents should ensure that the child:

• drinks plenty of water
• is physically active, as exercise has been shown to improve colon muscle movement
• eats a diet rich in fiber, including fruits and vegetables, and avoids processed foods and foods high in fat and sugar
• knows and understands to never "hold" or ignore the urge to move his or her bowel

On the toilet seat, toddlers should have their legs propped on a stool or a box for support with their knees at right angles, the doctors advise.