Constipation: Improving symptoms of constipation and soiling in children - Key messages for parents and carers

Introduction

You have been given this leaflet as your child suffers from constipation and soiling.

Symptoms of constipation and soiling may be managed with a range of treatments including laxatives, but symptoms will only improve and stay improved in the long- term, if some fundamental (essential) advice is consistently followed.

This information leaflet presents this fundamental advice as seven key messages.

Anatomy

After leaving the stomach, food passes through the small intestine where it is further digested and nutrients are absorbed. Waste material moves through the colon where water is removed and stool is formed. The stool is stored in the rectum before being passed out of the anus (back passage).

Message 1: Ensure your child drinks enough

To keep stool (poo) soft in the colon it is essential that children have enough water-based drinks each day. When there is too little fluid in the colon, stools become drier, harder and then difficult, and also sometimes painful, to pass.

To help ensure that your child drinks enough each day, they should have their own water bottle which they keep with them, including on their desk in school wherever possible. Marking intervals on the water bottle helps children to see how much to drink by certain times of the day. Some children may benefit from having two smaller water bottles per day rather than one large one; one to be drunk in the morning and the other one in the afternoon.

Charts called ‘wee checkers’ are useful tools to assess if enough drink has been taken, such as the one provided by ERIC (opens in a new tab) (the Children’s Bowel and Bladder Charity).

Message 2: Ensure your child has a well-balanced diet

Aim for your child to have a ‘well balanced varied diet’ (this is sometimes referred to as a “colourful plate of food” rather than a plate of foods of a similar colour). Your child’s plate should contain foods from the five food groups in the proportions shown in the Eatwell guide below.

Use of health food supplements, such as ground linseed and/or ‘fruit and fibre chewable cubes (for example Ortis cubes), may be advised depending on your child’s age as these can help improve the form of the stool and its transit through the bowel.

Message 3: Use a ‘pre-emptive’ toileting pattern

'Pre-emptive toileting' means that your child sits on the toilet at regular, planned intervals in the day rather than only when the sensation of needing to poo is felt.

As eating results in the contraction of the bowel, approximately 20 minutes after a meal your child should plan to sit on the toilet for 5 to 10 minutes. They should do this at least twice daily. Coloured egg timers can be useful for younger children to time themselves.

Message 4: Act on signs from your child that they need to pass stool

Young children will often change their behaviour or show signs that they need to pass a stool; for example, they may try and hide. Some young children will use their bodies to prevent themselves from passing a stool (this is called ‘withholding’) by, for example, standing on tip toes and arching to try to prevent the stool passing.

These behaviours need to be recognised by parents/ carers as signs that the bowels are trying to open. When this happens, sit your child on the toilet and encourage the active toileting methods described below.

Message 5: Active toileting whilst sitting on the toilet in the optimal position

It is important that your child sits on the toilet in a position which helps poo to pass.

• Children’s knees should be shoulder-width apart, with knees slightly raised so knees are higher than their hips. Younger children will need to use a footstool to achieve this position.
• Feet need to be flat on the floor (as long as the child is tall enough to ensure that their knees are raised) or on a footstool so that their feet are not dangling.
• Lean forward - the lower arms should be able to gently rest on the child’s thighs.

Children need to avoid passively sitting on the toilet, for example with technological gadgets or books. Instead, the attempts to try to pass a stool need to be active and focused.

Children need to learn to actively use abdominal (tummy) muscles whilst sitting on the toilet (called the ‘brace position’ or ‘moo to poo’) by, for example, making an elongated moo sound, blowing down a straw, blowing up a balloon or blowing bubbles to encourage stool to pass. Please see the Natural Constipation Relief in 3 Easy Steps ("MOO to POO") (opens in a new tab) video (under three minutes long).

Message 6: Maintain a bowel chart/ diary

Keeping a bowel diary can help you to identify patterns and so learn to work with your child’s body. For example, if a stool tends to be passed in the morning then ensure adequate time is routinely given to allow for sitting on the toilet at this time each day.

Bowel charts (such as the ‘Bristol stool chart’ shown below) can be a useful guide to help inform you when to increase or lower doses of laxative medication for your child. Laxatives designed to soften stools should be used/ increased when type 1 to 3 is being passed but decreased when paler brown stool of type 5 to 7 are being passed. If type 6 or 7 stool is dark brown in colour beware as this may be ‘overflow’ poo and a sign of constipation. Ask your child’s care team if you are unsure.

If you are unsure whether your child is constipated, it may be useful to perform a ‘sweetcorn test’ at home. Give your child a portion of sweetcorn to eat, then observe how many days it takes before there are signs of the sweetcorn in their stool. If you don’t see the sweetcorn over the next three days this might mean that your child is constipated.

Message 7: Positivity and engagement

The most important action you can take to help your child is to remain positive and help them positively engage with 'pooing'. Children of school age will benefit from being in a school environment where drinks are easily accessible (see message 1 above) and where they have easy and discreet access to a toilet where they feel their privacy is maintained.

We are here to provide support and advice to school teams where needed, so please call us on 01223 586973 if a letter to your child’s school would be helpful. The ERIC (opens in a new tab) website also has resources for schools.

Useful websites/ links

• ERIC (opens in a new tab), the Children’s Bowel and Bladder Charity, provides resources about children’s bladder and bowel problems for parents/ carers, professionals, schools and children.
• Natural Constipation Relief in 3 Easy Steps ("MOO to POO") (opens in a new tab) video (under three minutes long).
• The Poo Nurses (opens in a new tab) offer a 15 minute video on treatment of constipation and soiling with a ‘macrogol’ laxative (such as Movicol, Laxido and CosmoCol) including advice on dose manipulation.

Who shall I contact if I have any queries, concerns or questions?

For further information/ queries please contact the clinical nurse specialist team (Monday to Friday 08:00 to 18:00) on 01223 586973.