constipation prevention and treatment
Constipation as a longstanding problem can poison a person's life. A genetic predisposition may play a role. Some people reabsorb water too efficiently in the terminal gut, which leads to stone hard stools if they don't have a bowel movement at least daily, but most often dietary errors are the main culprit, such as a fiber poor diet, too much fat, or a low water intake. Often the child is reluctant to have a bowel movement, because of a previous unpleasant experience of large hard stools causing an anal fissure, painful thereafter with each bowel movement. This leads to a lazy gut, i.e. an intestine with a low baseline activity, which cannot be raised by a sheer improvement of dietary habits.
To prevent chronic constipation, early attention and interventions are useful, but the first step is the ability to tell true from false constipations in infants.
A breast-fed baby may have a bowel movement once or twice a week, and even less often. If the infant is comfortable, without abdominal distension or colic, if stools are soft enough to be expelled easily and without pain, the situation is normal. Laxatives or worse, discontinuation of breast feeding, would not make any sense.
If the baby is bottle-fed, the approach must be different. Some formulas are known to induce softer or liquid stools, others hard and dry stools, and some chronic constipations can be dated back to that early age.
To solve a constipation problem in infancy, the simplest step is to switch to formulas such as Omneo or Nan transit. Their composition is devised to induce softer stools. It is safe to add a small amount of lactulose. Start with 2.5 ml in the first morning bottle, increase gradually (4-5-6-7 ml...) as necessary.
Lactulose is chemically close to lactose, the natural milk sugar. It is a soft laxative which does not induce dependency, on the contrary. Whenever it turns out to be necessary, middle or long term lactulose use tends to reeducate the gut, gradually raising its baseline activity.
A common technique is to prepare bottles with commercially available "Hépar" water, rich in magnesium sulfate, a salt with laxative properties linked to its ability to irritate the gut. Occasionally this is acceptable but long term use is questionable. Glycerine suppositories may also be used, from time to time, and mostly as a lubricant, but on a more regular basis, can induce a dependency.
It is not uncommon to observe episodes of acute constipation, leading sometimes to severe distress, emergency room visits, even hospital admissions, when solid foods are being introduced. This may look paradoxical since vegetables, fruits and cereals contain fibers, absent from milk. The mechanism is a reduced liquid intake. Whenever a bottle is replaced by a solid meal, the baby must at the same time start drinking enough water.
Some stubborn constipations, observed in infants or toddlers, are difficult to explain, they seem to resist all efforts : the diet may be rich in fibers, the child drinks enough, and even laxatives are poorly effective. Then an organic cause must be suspected : rarely a congenital anomaly such as Hirschsprung's disease, much more often cow's milk allergy. The latter can cause severe resistant constipation, sometimes without any other obvious symptoms.
A child with hard stools, which accumulate and are retained, because their expulsion is painful and difficult, can seldom be helped by dietary measures alone.
Of course, it is essential to insist on an adequate diet. It must be rich enough in fibers (of the three kinds : cereals, fruit and vegetables) and water.
Dietary fat may have to be reduced. Contrary to a common belief - and unlike laxative mineral oil - they slow down gut transit and may contribute to constipation.
But successful chronic constipation treatments require the overcoming of two obstacles : gut "laziness" and the child psychological resistance. Only the use of one or two laxatives, at appropriate dosages and as long as needed - months or years sometimes - can solve these difficulties.
Lactulose can be increased at will. The medication has no toxicity (if used for coloscopic preparation, the patient is instructed to drink the whole bottle). Psychological tolerance is the only practical limit. Digestive cramps experienced when the gut regains a higher level of activity respond to a transient dosage reduction. It may be necessary to add a second laxative such a inulin (a non digestible sugar, with prebiotic properties, i.e. favourable to a healthy intestinal flora). It is sold in pharmacies under the name "Fibion effervescent" tablets.
These laxative sugars share the ability to reeducate the gut without risking any dependency. Sometimes, for resistant cases, a ballast laxative must be added such as Movicol, particularly useful in case of acute constipation (fecal impaction, see protocol).
If this does not succeed in solving the problem, a more potent laxative such as picosulfate (as "Laxoberon" oral drops) may be needed transiently, ie for a few weeks, but the dosage should be limited and reduced gradually as soon as possible since it may cause a dependency.
All these measures aim at obtaining stools soft enough, and if needed almost liquid, to ensure that the child does not retain them. If the resistance to overcome is high, there is no other way to make progress.
If the child still wears napkins (diapers), an accident matters less. Otherwise it may be necessary to reintroduce them. If the patient cannot hold a bowel movement, which may be a necessary phase on the road to recovery, napkins are inevitable.
The result once obtained, i.e. a least one bowel movement daily, expelled easily, without pain or reluctance, medications needs are expected to decrease spontaneously. Eventually, it should be possible to discontinue all medications but this decision should not be taken before a completely normal schedule is achieved.
If not, it is certainly better to maintain a low level of intervention, with a daily non addictive and mild laxative, than to tolerate a persistent low grade constipation.
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