An expert look at treatment options for children’s chronic constipation

Recurrent episodes of constipation can significantly affect a child’s wellbeing and general health as well as disrupting their daily routine. Fortunately, a number of conservative (non-surgical) treatment methods and lifestyle modifications are able to help children struggling to maintain a pattern of regular bowel movements. In this informative article, second in his series on chronic constipation in children, renowned consultant paediatric surgeon Mr Brian MacCormack sheds light on the various approaches to treatment and details when surgical intervention is required.

How is chronic constipation in children treated?

If constipation in children is identified early, it can often be much more straightforward to treat than if it is not carefully addressed until things have got much worse. The basic principles of treating childhood constipation are as follows:

• A careful history and examination to exclude the rare medical conditions that can cause constipation
• Increase activity levels - children who are more active will significantly reduce their tendency towards constipation and this is part of a healthy lifestyle for any child.
• Ensuring adequate water intake (See NICE guidelines below) - reward charts can be helpful to develop this in many younger children.

• Ensuring a healthy, balanced, high-fibre diet - it is critical that families and children are supported to address their diet.

• Develop the gastro-colic reflex - this is a natural reflex in the body where the pelvic floor relaxes around thirty to sixty minutes after a meal. Children should try to do a poo thirty to sixty minutes after their evening meal every day. They should be rewarded for trying, not just when they do a poo.

• Support for children and families - if an older child is supported they will often take ownership of their own condition and this is an excellent starting point. Websites from organisations such as The Children’s Bowel and Bladder Charity are incredibly rich resources (downloadable charts, videos, telephone helpline) for children of all ages and their parents.

• Medication by mouth - these come in two main forms:

Osmotic laxatives (e.g. Laxido / Movicol) - these medicines work by keeping water in the stool and therefore making them softer and easier to pass

Stimulant laxatives (e.g. Bisacodyl / Picosulphate / Ducolax / Senna) - these medicines actually make the bowel squeeze to help the child pass the stool (sometimes they can cause cramps)

• Medication in the bottom - also called suppositories, these are thankfully not needed in most children who are identified early and treated effectively with the other measures above. However, suppositories or other medication given into a child's bottom (enemas) may be necessary in severe constipation. These medications can be extremely effective because they ensure that the child's rectum (the last bit of the bowel) is empty more often than not and would be considered a much more targeted approach in some cases.

When is surgery required to treat chronic constipation?

Surgery is required in rare cases (less than five per cent) that have an underlying surgical cause for the constipation. Surgery may also be occasionally required in children with severe chronic constipation where all of the usual treatment strategies (as outlined above) have failed.

What does this type of surgery involve?

Thankfully the vast majority of children with chronic constipation can be successfully managed without the need for surgery. In some circumstances, children who have not passed a bowel motion for more than a few weeks may need to be admitted to hospital for more intensive medical treatment. This is called disimpaction and can involve larger or stronger doses of medications by mouth and also frequently medication into the bottom (enemas).

If this is not successful a child may be referred to a surgeon like me for a procedure called a manual evacuation. This is where the large hard poo is manually removed via the child's bottom under a short general anaesthetic. It is critical that all of the basic principles of managing constipation are followed after a manual evacuation otherwise there is an extremely high failure rate where after a number of weeks or months the child is back to square one with regards to their chronic constipation.

Antegrade Continence Enema (ACE) procedures are used for children who have severe chronic constipation and have failed the typical non-surgical management. This procedure is performed under general anaesthetic with key-hole techniques. A small tube or low-profile 'button device' is placed through the right side of the tummy wall and into the appendix or large bowel (caecum). This allows medications (washouts) to be given into the first bit of the large bowel and can be extremely effective in managing severe constipation. The child needs to be able to sit on the toilet for about 1 hour each day to allow the ACE washouts to be delivered. Some children who won't sit for this long are therefore not suitable candidates for this procedure.

Finally, rarely in children with extremely severe constipation a temporary colostomy (stoma) bag may be offered. Clearly this is a significant decision for any child or family but for some it can be life-changing.

If you are concerned about your child’s recurrent constipation and wish to book a consultation with Mr MacCormack, you can do so by visiting his Top Doctors profile.