Constipation%20in%20children Patient Education

• Family education includes providing information on the mechanism of constipation
• Encourage parents to have a consistent, positive and supportive attitude during treatment
• Knowing the precipitating factors of constipation helps remove anxiety of parents and caregivers and encourages them to be involved in its management
• Educate the parents on the proper timing and techniques of toilet training
  • Toilet training should only be started when the child is developmentally ready or shows signs of readiness, and using a relaxed approach
  • A potty chair or foot support (if adult-sized toilet is used) should be provided
• Treatment may be long and irregular and characterized by improvement alternating with relapses

Behavioral Therapy

• Aims to regularize toilet habits, discourage stool withholding and improve understanding of defecation dynamics
• To establish a regular bowel habit, recommend scheduled toileting appropriate for the child’s developmental stage, with adequate time for bowel movement
  
  • Encourage the child to sit on the toilet for 5-10 minutes after meals; when in school, it is alright for the child not to go to the toilet
  • Advise parent to give child enough time to spend in the toilet when child shows signs of withholding stool
• Straining techniques such as relaxation of legs and feet, taking a deep breath then pausing while pushing while holding one’s breath, should be taught to the child
•  Maintain a bowel diary of stool frequency and consistency which can be discussed during clinic visits
  •  For positive reinforcement, encourage and reward the child’s efforts and not the results
•  It may be of benefit to refer to a mental health provider for intervention if behavioral problems interfere with treatment, but it is discouraged to do it routinely

Biofeedback Therapy

• Uses devices (electrical or mechanical) in order to increase awareness of physiological functions of anal sphincter by providing the patient with visual, verbal and/or auditory information and enhances self-control on body functions
• With the rise of the rectal pressure, patients are taught external anal sphincter relaxation
• Demonstrated efficacy in correcting abnormal defecation dynamics in previous studies but failed to show additional benefit in the treatment of chronic childhood constipation
• Currently used only for children with pelvic floor dyssynergia and short-term treatment of intractable constipation
• Not to be used for ongoing treatment of children with functional constipation

Dietary Modification

• Although commonly recommended for treatment of functional constipation, it is discouraged to use dietary modification alone as 1st-line treatment
• For infants, the following are recommended:
  
  • Continue breastfeeding
  • For formula-fed infants, partially or extensively hydrolyzed infant formulas with prebiotics offer a good alternative for managing functional constipation
  • Helpful for infants are complex carbohydrates [eg carob bean gum, galacto-oligosaccharides (GOS), inulin] and sorbitol present in some juices, eg apple, prune, pear, which increase stool frequency and fecal water content
  • Barley malt extract or corn syrup can be used as stool softeners
• A high-fiber diet is encouraged to help form soft bulky stool in children
  •  A 0.5 g/kg body weight intake of fiber is recommended in children >2 years
  •  A balanced diet with fruits, vegetables, and whole grains is appropriate for treatment
•  A double-blind crossover study demonstrated intolerance to cow’s milk may result in constipation; however, withholding milk from the diet should be done only on the advice of a specialist, as it is not a common occurrence
  • May consider elimination of cow's milk protein for at least 2 weeks in patients unresponsive to other interventions especially if with atopic symptoms
• Probiotics (eg Lactobacillus sp, Bifidobacterium sp) may help improve stool frequency and consistency; however studies are limited and further trials are needed to support the use of probiotics in children with functional constipation
•  Increased intake of fluids is also recommended; however, studies have shown that doing so only increased urine output and had no effect in output or consistency of stool and did not improve stool frequency
  •  Increase intake of absorbable and non-absorbable carbohydrates especially sorbitol, found in some juices like prune, pear and apple juice