Dr. Vivek M. Rege
Pediatric Surgeon & Pediatric Urologist
B J Wadia Hospital For Children, Hurkisondas Hospital, Wockhardt Hospital, Mumbai
In recent times, with the advent of small nuclear family, working parents and availability of fast foods in cities, this has become a very common complaint. I must be seeing at least 4 new children with constipation each month. Theoretically there are multiple causes for constipation but almost all boil down to one common cause improper diet of the child. The reasons for a wrong diet in a child are excess intake of milk daily, feeding of soups and fruit juices; eating junk foods and filling the tummy with wafers, chips, biscuits etc. The wrong type of food at the wrong time in the wrong quantity leaves little for the right food in the right quantity. Inadequate fibre and low residue leads to constipation, this in turn leads to loss of appetite, hence decreased intake and further constipation. Additionally, with constipation comes passage of hard stools with painful defecation and hence the child tries to avoid passing stool and looses appetite and a vicious circle ensues. Another reason in such cases is a child of 2 years is still being fed milk through a bottle with a nipple!! This child is given 4 5 feeds of milk to a total of almost 1 11/2 litres milk daily leaving no space for eating other food. There are many things wrong in this approach total dependance on milk as the source for proteins, carbohydrates and fats is far below adequate in a growing 2 year old. Feeds given by bottle are bad for the child since the child is able to swallow the milk fast, and along with it the air is swallowed and the stomach gets filled and remains for a long period. This leaves no incentive for the child to take the effort of taking solids, putting them in the mouth manually, then chewing each many times and then swallowing it and the child likes the easy and fast way of taking meals bottle milk. Also, the child is used to only one type of taste, and does not like vegetables each having a different taste. The child goes for the axiom maximum satiety with minimum effort in the shortest time.The therapy for these children is of course to correct the diet under supervision of the doctor.
This does not mean other causes should not be looked for. There may be anatomical causes like a small size anal opening in the child, which makes it difficult for the child to pass stools and the child strains, and the pain is awful and hence passes little at a time to avoid prolonged pain. In some children, the anal opening is situated slightly ahead and is narrowed or stenosed giving rise to physical cause of constipation that needs correction. These conditions require a surgical intervention to make the opening in the correct position and also adequately large size for the stool to be passed easily.
Anal opening situated anteriorly & stenosed
Although the cause of the constipation is an improper diet, most parents and even the doctors will insist on giving only laxatives or purgatives and not bother to correct the quality of the diet. One of the things that I enquire in detail when parents bring a child with constipation is about the dietary intake per day. In almost 90% of cases this will be the cause of the constipation. Correction of the diet is easier said than done. To begin with I prefer to divide the diet into 3 components: one that must be eaten on a daily basis; the second part is one that may be eaten over and above the first part; and the third component is a list of eatables that are not to be given to the child at all under any circumstances for at least a month. The parents, grandparents, uncles and aunts are strictly forbidden from interfering in the supervision of the childs diet, all in the house have to be very strict about what the child is allowed to eat or not, though it may seem cruel at times. The child soon realizes that if I dont eat the food being given to me, I may have to starve, so, I might as well eat what is given and make the best of it. The first component consists of eating adequate quantity of vegetables, salads and dals for lunch and dinner. In between lunch and dinner the child is given all fruits to eat. Over and above this compulsory component is the second one that the child may have is roti, rice and bread daily but not at the cost of the first. Also the child may be given non vegetarian food if desired like meat eggs, chicken. The last component is those foods that are to be avoided like chocolates, biscuits, chips and other miscellaneous food. Under strict supervision and a regular follow up, some stool softeners are given together with digestives. However, once the diet is normal and balanced, these medications are discontinued. The time required from starting the therapy to successful completion may vary from months to years depending on an individual child and the family.
In some children with constipation from birth, that persists despite proper diet, a local cause must be looked for or, a systemic disease. A common complaint by the parents would be that the child cries a lot when passing stool and there may be some blood in the stool at times. This is caused by a split in the tender skin just at the edge of the anal opening called a Fissure. The crack in the skin is highly painful and passage of hard stool makes it worse. The child gets pain during defecation and hence tries to hold back the stool, this in turn makes the stool dry and harder than before and therefore when passing such a stool with pressure, the anal opening has to open wider and also the fissure gets stretched and pains and the cycle continues unless broken. In such children the ideal initial therapy is to apply local anesthetic cream or gel to the peri anal area to anesthetise the fissure, take away the pain and the fear of the pain, let the child pass stool painlessly and freely. Once the rectum gets emptied well, the child regains appetite, eats well, passes soft stool and the fissure heals. In some children, this may not work and the child gets a spasm or continuous contraction of the sphincter due to the pain. In such cases I take the child under anesthesia and stretch the sphincter to break the spasm, allow the child to pass stool without the spasm causing constipation and give rest to the fissure allowing it to heal.
There are a few children who are born with an abnormal intestine mainly the large intestine. In this condition, there is an absence of a type of cell known as Ganglion cell in the intestine of the child. The passage of food in small intestine and passage of feces in large intestine is based on segmental peristalsis pushing the bolus forward. There is a contraction of the segment containing the bolus and this is followed by relaxation to allow the next bolus to enter the intestinal segment, and this goes on. In children with absence of Ganglion cells (Aganlionosis), this ability to relax a segment of the intestine is lacking, hence the large intestine containing the fecal matter reaches a point till Ganglion cells are present, and then the intestine is in a permanent state of contraction with no relaxation to allow the next bolus to come in and hence the child goes into constipation. The segment of intestine that is abnormal may vary from a very small segment to at times the entire large intestine. In such children, there is no easy therapy other than removal(excision) of the diseased segment of the intestine. In this disease called Hirschprung Disease, the abnormality starts from the anal opening and progresses upwards to give the length of the abnormal segment. Thus removal of the abnormal segment has to followed by bringing the normal intestine down to the anal opening to form a new rectum that is free from disease. Thus this condition needs an accurate diagnosis before proceeding for the correction.
Narrow abnormal segment
There are mainly 2 investigations for this, A) Barium Enema - this consists of filling the rectum with a contrast liquid barium and looking at the large intestine. The abnormal segment will be thin and contracted, the normal segment will be dilated and is proximal to the abnormal segment.The accuracy of this method is about 75% only.
B) Full thickness Rectal Biopsy ; here, a small piece of the rectum is taken surgically and is sent for examination under the microscope to look for the Ganglion cells and nerve bundles. In cases with Hirschsprung disease, there will be no Ganglion cells and will have excess nerve bundles. This is almost 100% accurate. Once the diagnosis is confirmed, then the only answer is surgery. This may require staged surgeries , or may be done with a single stage surgery. This depends on the condition of the child, his/her state and size of the large intestine and other factors. If the exact length of the abnormal intestine is known and is excised, the results are usually uniformly good with minimal complications.
Last Updated: 27th January 2009