By: Ann Costigan & Stephanie Orr
Here are a few steps to make it easier for children to build healthy toilet habits
A mother was overheard talking to her husband on the phone while going home on the bus. “Yes, I was at the doctor’s with Seán. It was a waste of time going through the same old story: eat a healthy diet, drink enough water, go to the toilet regularly, take his medication and he’ll be grand. Sure, he said that the last time and the time before that and he still hasn’t gotten any better. I just know there’s something wrong with his bowel, there has to be.
“Oh love, will you put some chips and sausages on and make sure we have some coke in the fridge – little Seán deserves a treat.”
Little Seán is typical of one in three children here who suffers with constipation. This is a hugely underestimated problem, but thankfully it is very treatable if the correct treatment plans are followed.
Every parent fears that constipation is in fact something more sinister and that there must be an underlying cause. It is, of course, imperative that your child is reviewed by a doctor and a correct diagnosis is made.
If there are any worrying signs, further investigation is warranted. However, it is very reassuring to know that 90-95 per cent of cases are idiopathic. This means that there is no known cause. Soiling is common place with constipation and some parents feel that it is just because the child is being lazy. They are not. This is overflow diarrhoea due to impacted poo – loose poo is seeping out around the hard poo. The child has no control over this.
But why is little Seán still constipated if he is doing everything the doctor said to do? Okay, let us look at what the doctor said to do and this time answer the questions honestly.
How my bowels work
First: does little Seán understand how his bowels work? It is important that you teach your child how poo is made and why we need to go to the toilet. It is surprising how many kids don’t understand how their body works.
Poo isn’t the usual topic of conversation at the dinner table but you can find a more suitable time to talk about it.
Defecation (having a poo) is a complex process that we sometimes take for granted, until there is a problem. The process involves the abdominal and pelvic muscles and also the anal sphincters (internal and external). The food we eat every day takes 24-48 hours for our digestive tract to break down and digest. This is called the transit time.
When it gets to the rectum, the internal sphincter is told to relax to let the poo out. However, the external sphincter will hold in poo until we have found a toilet and then we relax this muscle to let the poo out.
We also have what is called the gastrocolic reflex. When we eat a meal, the stomach fills and sends a signal to the rectum to contract. This is the food from the previous day or two that we have now digested and is ready to be excreted.
This is why we feel like making a poo after a meal.
The reflex can take up to 30 minutes to work. This is the best time to toilet your child.
Importance of a healthy diet
Secondly: does little Seán really eat a well-balanced healthy diet and drink enough water every day? The only way you can answer this question honestly is by keeping a diary of what your child eats and drinks every day for a few days.
Do you know how much fiber is recommended for your child? (See panel). Get into the habit of looking at food labels to see what the fibre content is and make a conscious effort to reach the daily target. Be inventive with food; add some extra seeds to cereals and homemade breads.
You don’t have to be the next Mary Berry to make breakfast muffins or breads. There are countless recipes freely available on the internet.
Check out hse.ie/healthyeating or healthpromotion.ie for excellent booklets on healthy eating for children and the whole family. Get your child involved in preparing food with you – make it fun.
Do you know how much they should be drinking each day? (See panel). Get them their own drinking cup with a straw; make it more enticing for them. They don’t just have to drink plain water. Also, some fruits have high water content or you could make some jelly or ice lollies for example.
Make a star chart for your child and give them a sticker at the end of the day if they reach their daily target of fluid and fiber. This might seem like a useless exercise but if you explain to your child what you are doing and if you stick to what you are saying, the majority will play along with it. Then at the end of the week if they have reached all their goals, they get a treat.
Limit the number of treats they get during the week so that they have something worthwhile to work for.
However, fluid and diet alone will not treat constipation.
Stay the course with medication
Third: Medication. Maybe little Seán didn’t like the medication he was on and so didn’t take it or maybe he had a poo and his parents didn’t think he needed it any more. Unfortunately, some medication doesn’t taste nice but it is necessary.
Also, medication takes time to work so do not expect immediate results. Medication is so important.
When your child is constipated there is a build-up of poo in the bowel. The bowel has an amazing capacity to hold onto a lot of poo. Time to bulk buy on the loo roll and air fresheners! A high dose of medication to clear out this build-up is necessary. It will cause cramps and your child will poo a lot but that’s the result we are aiming for.
After the initial clear-out of poo with a high dose of medication, maintenance medication is then required. There is a variety of medications that the doctor may prescribe for your child to help treat their constipation.
These medications may need to be taken regularly for some time before your child’s bowels return to normal. They will not make your child’s bowel “lazy”. Do not stop medication until you have discussed it with your child’s doctor.
When the medication has done its job and your child’s bowels have returned to a normal pattern, medications can be slowly reduced, not stopped abruptly. Your doctor will advise you how to reduce medication.
The types of laxative available for children are divided into different groups depending on how they work: bulk-forming laxatives, stimulant laxatives, stool softeners and osmotic laxatives.
Your doctor will be able to explain these in more detail.
Toileting & Exercise
Fourth: Timed toileting is imperative and must be implemented into the daily routine. It can prove difficult to get your child to sit on the toilet, let alone correctly.
Children tend to find that they haven’t the time to spend on the toilet and so quickly hop on and off it without concentrating on what they should be doing. Correct positioning can help to empty the bowel more efficiently. Here are a few tips on achieving this.
Make sure the bathroom is warm and inviting.
Use the body’s natural gastrocolic reflex. This is strongest in the morning and about 20-30 minutes after main meals.
Try to keep to a routine, using the toilet around the same times every day and also when your child says they feel the need to go – always respond to the body’s urge to poo.
Do not leave the child sitting on the toilet by themselves for long periods of time, 5-10 minutes is enough.
Ensure the toilet is comfortable to sit on. Some children fear that they will fall into the toilet and so it is important to get an add-on seat for smaller children.
Use a footstool to ensure their feet are supported.
Put some toilet paper into the bowl first so that there is no splash back when a poo is passed. Some children get a fright if there is a splash.
When sitting on the toilet your child should be able to lean forward and rest their elbows on their knees with their knees higher than the hips
Your child should be relaxed when sitting on the toilet and not straining.
Talk to your child when following these steps so that they know what you are trying to achieve.
Allow your child to blow bubbles or blow up a balloon so as to increase their inter-abdominal pressure.
Encourage your child to look at what they passed into the toilet – use the Bristol stool chart, available on the internet.
Encourage your child to flush the toilet as part of the process of going to the toilet. You can put some food colouring into the cistern and your child can guess what colour the water will be. Make it fun!
Teach your child how to wash their hands after using the toilet.
Use a sticker reward chart to praise positive behaviour.
Avoid letting your child use anything that may distract them while on the toilet (e.g. computer games or mobile phones) as this may prevent them from concentrating on making a poo.
Daily exercise for at least 30 minutes is recommended and may help with constipation. Many children tend to play computer games and watch television, meaning they have sedentary lifestyle. Daily exercise will also help to prevent obesity and associated diseases in adulthood.
No quick fixes
Idiopathic constipation with associated soiling is distressing for the child and family. The child and their parents need to understand this condition and how to fix it.
They need realistic expectations and to understand that more than half of children suffering with constipation will relapse and may need repeated doses of clear-out medication.
Treating this problem takes time, effort and commitment. There is no quick fix. However, with a clear plan of treatment and realistic expectations, it is very treatable. In the following articles we will look at the following in more detail:
- How the bowel works
- What is idiopathic constipation
- Medication management
- Fluids and fiber
Ann Costigan (RSCN, BSc Nursing Management) is a Colorectal/ Stoma Clinical Nurse Specialist in Our Lady’s Children’s Hospital. She qualified in Children’s Nursing in 1999 and has worked as a Staff Nurse, Clinical Nurse Manager and Clinical Nurse Facilitator.
She has been working in Colorectal/ Stoma Care since 2010 and has a special interest in Idiopathic Constipation. Ann, in conjunction with her colleague Stephanie Orr, has written a number of articles on Constipation which have been published in national and international medical journals. They have also developed a booklet for use by Doctors to diagnosis and treat constipation. This booklet has been shortlisted for the HSE Excellence Award and also have been awarded the Clinical Nursing Award in Our Lady’s Children’s Hospital, Crumlin for this work.