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| |    Treating Severe Constipation by Robert Needlman, M.D., F.A.A.P. reviewed by Laura Jana, M.D., F.A.A.P. The key to successfully treating severe constipation in a school-age child is that the child understands what's going on and takes responsibility for getting better. It's best for parents and doctors to act as coaches, encouraging and helping the child. When parents take over the problem, children tend to act passive and helpless, just the opposite of the attitude that will get the problem solved. A two-step process What about the mechanics of dealing with constipation? The development of chronic constipation involves the accumulation of hardened stool, with stretching and loss of function of the colon (large intestine) and anus. Because of this, the first step in treatment is usually to clean out the old, hard stool from the colon. The second step is to keep BMs soft and regular. This "maintenance treatment" usually has to continue for several months, or even a year, because it may take the colon that long to regain its shape and function. Step one: clean out If your doctor decides that it's necessary to clean out the colon, there are two options: laxatives or enemas. Both ways can work, although which one is best depends on the particular child. A child who becomes terribly upset at the thought of having to swallow mineral oil, for example, might prefer enemas. Other children have very different feelings. In either case, if the colon is really packed with old stool, it may take several days of treatment to clean it out. Whatever the situation, you should always enlist the support of your child's physician before taking this step. Step two: maintenance The goal of maintenance is to have a large, soft stool every day or every other day. Along with laxatives, changes in behavior and diet also are important. Behavior changes include sitting on the toilet for 10 to 15 minutes, two or three times a day, to allow the intestines, rectum, and anus to learn how to work together to produce a BM. Exercises to strengthen the abdominal muscles also help. Together these behavior changes allow a child to feel that he is actively making himself better, not just waiting around while the doctors and parents do their work. Diet changes involve three things: increasing water, increasing fiber, and cutting out foods that are constipating. Most children need four to five large glasses of water (or juice) per day. Fiber-rich foods are fruits, vegetables, and bran. (See our article on following an anticonstipation diet for details, including potentially constipating foods.) Medications Many children need to use laxative medications, with doctor supervision, for a long time--several months--until their colon is back in sufficiently good shape. These medications come in different varieties. Some simply work like dietary fiber: They sit in the intestines and draw water into themselves by osmosis, becoming large, soft, and fluffy. Common brand names include Metamucil, Maltsupex, and Lactulose. Others work by stimulating the intestines to squeeze harder (brands include Senekot and Dulcolax). (With these medications, in general, the brand name products are no better than the cheaper store brands or generics next to them on the shelf, so I usually buy the generics.) Mineral oil works partly by stimulating intestinal movement and partly just by lubricating the stool. Mineral oil doesn't have much taste (it really is very bland), but most children hate the oily texture. Mixing it with chocolate syrup can help; so can freezing it overnight. The consistency of frozen mineral oil is like runny caramel. Drug stores sell flavored mineral oils; they are relatively costly, but many children find them more acceptable. Most often I recommend starting with three or four tablespoons of mineral oil a day, increasing the dose if stools remain hard or decreasing the amount if there is diarrhea or too much oil leakage (although a little leakage, enough to stain the underpants, is to be expected). Because mineral oil can interfere with the body's ability to absorb certain vitamins, children who are on mineral oil for a long time often benefit from a once-a-day multiple vitamin, taken at whatever time of day they are not taking the mineral oil. With all of the medications discussed above, it's very important to check with your child's doctor before you use them. They all have a variety of side effects and can interfere with the beneficial effects of other medications your child might be taking.
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