Jane is an outgoing 58-year-old mother from Liverpool, but behind her bubbly exterior is many years of pain due to a complex history of surgery.

Following complications after a total hysterectomy and large bowl resection in 2005 Jane found herself living with the symptoms of a functional bowel disorder, including chronic constipation and faecal loading.

Constipation is a common condition, affecting around 20% of men and woman of all ages in the UK. It can cause stomach pain and make you feel bloated and nauseous.

While many people find that simple changes to their diet or lifestyle can help improve their symptoms, others, like Jane, have underlying problems which means the condition persists.

The limits of lifestyle changes

After an abdominal operation in 2016, Jane was admitted to hospital several times due to recurring faecal loading. It impacted her confidence and her mental health began to decline.

Despite following the guidelines about healthy living and strictly adhering to her oral laxative regime, she grew increasingly frustrated with healthcare professionals who kept suggesting further lifestyle changes.

It was only after her fifth hospital admission in 2018 that she was finally diagnosed with a functional bowel disorder. Though the damage couldn’t be undone, she was referred to a specialist who suggested she try transanal irrigation (TAI).

Help with managing constipation

Transanal irrigation (TAI) is a way to help manage constipation and faecal loading. It’s a simple procedure in which body temperature water is passed through a soft silicone cone or a catheter into the rectum, to assist in the safe evacuation of stool from the lower section of the bowel. 

Jane explains that there was a bit of trial and error before she was comfortable with the procedure but was glad she stuck with it because ‘within a few months my life changed completely.’

After years of feeling like her life was on hold, she was suddenly able to look forward and plan ahead.

‘It’s really changed my life.’

This article is part of the Education Spotlight on Constipation, supported by Renew Medical. You can also read more about constipation in our information library.

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Transanal irrigation (TAI) is a management option for people who suffer from constipation. Here, we look at best practice for those who are using TAI for constipation to make sure it is as safe, comfortable and effective as possible.  Remember, it is always best to discuss the issue and any treatment with your doctor.

How do I get the best results from transanal irrigation?

Before commencing irrigation, it is advisable to familiarise yourself with your irrigation system.
Following the provided instructions for use, assemble the product, fill with water and pump
through the system.

It can take a little time to get used to irrigating, and for the bowel to become accustomed to the
procedure. It may take 2–4 weeks to get into a well-practiced routine. It is important to irrigate at a
similar time each day and to allow yourself enough time to complete the procedure thoroughly.
The process takes approximately 20-35 minutes and should be performed regularly (usually every 24 or 48 hours) to achieve the best results.

For those with reduced, or no bowel/rectal sensation, it is advisable to stay close to the toilet
post-irrigation, until you have a routine that works well for you. It is a good idea to use a disposable absorbent pad immediately after performing irrigation.

You can repeat the irrigation process if required. If you are unable to feel the urge to open your bowels, then you can use measured of amounts of water to achieve the right volume for you. It is best that you speak to your clinician to discuss what is right for you.

As irrigation cleans the lower portion of the large intestine it can help to:

• Reduce the risk of constipation by preventing the build up of stools
• Reduce the risk of faecal incontinence and leakage in-between each evacuation
• Regain control over your bowel management
• Reduce the amount of time spent on your bowel care

This article is part of the Education Spotlight on Constipation, supported by Renew Medical. You can also read more about constipation in our information library here.

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Constipation is common, but there are management options that can help. Here we take a look at how transanal irrigation helped one teenager manage his condition.

Rugby-playing Joe, 14, suffers from idiopathic constipation, a type of constipation where the cause is unknown. An estimated 1 in 100 children and young people suffer from the condition. Symptoms include painful bowel movements and bowel movements that are hard, or difficult to pass . Sufferers may also soil their underwear, which is something Joe is particularly familiar with, experiencing ‘accidents’ between 8 and 12 times a day.

According to Michael, Joe’s father, Joe has struggled to control his bowel movements all his life. At primary school he had to take a nappy sack in with him, along with clean underwear to change into. It wasn’t until he was eight that he was diagnosed with idiopathic constipation, but even then, the process was long and often fraught. ‘It was overwhelming,’ Michael says, particularly as the initial treatment Joe was prescribed ‘made (the condition) a lot worse.’

While Joe – an otherwise typical teenager – has a laissez-faire attitude toward it all, describing these years as “a bit of a pain,” his father is more outspoken about the anxiety and stress it had on the family. “It’s been a weight on my mind,” he says. ‘I’ve been climbing the walls.’

Joe, too, admits that his insecurities growing up often prevented him doing the things he wanted to do, such as staying over at a friends house.

“He’s growing up and getting older now,” Michael says. “There’s a lot more self-consciousness and body shaming happening. He got self-­conscious that someone might pick up on an accident he wasn’t aware of.”

Help with managing constipation

Things changed around six months ago when Joe’s doctor suggested transanal irrigation (TAI).  TAI is a simple procedure in which body temperature water is passed through a soft silicone cone or a catheter into the rectum, to assist in the safe evacuation of stool from the lower section of the bowel.  

Though Joe was already familiar with using suppositories, he hadn’t used TAI before and he initially worried it might be uncomfortable or difficult to use. “I wasn’t sure about it at first,” he says. But to his surprise, he found the system soft and comfortable. “It doesn’t hurt at all,” he says.

Now, Joe uses an irrigation system every morning before school. It takes him between ten and twenty minutes, and he passes the time watching a show on his iPad. In the evening, he takes a laxative treatment.

“A dramatic change.”

Michael remembers the day he started his new regime. ”He came home from school and there was an actual swagger in the way he walked. That sense of relief, you know?”, he says. Joe says he feels a lot more sociable now. He’s also confident enough to enjoy rugby and other contact sports without the fear of an accident.

“His sport and social life have changed dramatically,” Michael says. “It’s really made a tremendous difference. It’s improved things vastly.”

“It really has helped,” Joe agrees. “I’m not worrying about anything now. It’s great!”

This article is part of the Education Spotlight on Constipation, supported by Renew Medical. You can also read more about constipation in our information library here.

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TAI is a simple procedure in which body temperature water is passed through a soft silicone cone or a catheter into the rectum, to assist in the safe evacuation of stool from the lower section of the bowel. TAI is usually self-administered and carried out at home.

During TAI, as the water fills the rectum, the rectal wall gently stretches, until there is a desire to open your bowels and any stool and water is emptied from the bowel.

The irrigation process may be repeated if required. If you are unable to feel the urge to open your bowels, then measured volumes of water can be used. It is advised that you speak to your clinician to discuss what is right for you.

The process takes approximately 20-35 minutes and should be performed regularly (usually every 24 or 48 hours) to achieve the best results. Transanal irrigation can reduce the amount of time you have to spend on managing your constipation and can make improvements on quality of life. Rectal irrigation can offer improvement of the symptoms of faecal incontinence, evacuatory disorders and constipation, and are sometimes recommended when other therapies have failed.

This article is part of the Education Spotlight on Constipation, supported by Renew Medical. You can also read more about constipation in our information library here.

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Top Tip If you notice any persistent change in your bowel habit, such as needing to go to the toilet more often, having looser stool, bleeding from your bottom or stomach pain please visit your GP, as these symptoms could indicate other problems.

It is normal to feel embarrassed about speaking to your doctor about constipation but they are trained to help you. It is important to seek medical advice from a doctor or nurse if you have noticed changes in your bowel habits that concern you, or if you are in discomfort.

When you go to the doctor it can be helpful to make a note of your symptoms to mention, and if you have kept a bowel diary you could take this with you. The list below may be helpful. Try and remember at least three points that apply to you and so that you feel prepared for your appointment:

• Do you feel uncomfortable or distressed?
• Do you spend a long time in the bathroom with little or no results? How long?
• How often do you poo?
• What type of poo do you usually have? Take a look at the Bristol stool chart to identify the type.
• How long you have you been suffering for e.g days/ weeks/ months/years?
• Tell the GP about treatments that you have already tried for constipation including over the counter medicines

The GP is likely to discuss your lifestyle with you. They may suggest trying a course of medication to help regulate your bowel, or they could refer you to a specialist service.

A specialist service will vary depending upon where it is located in the country. Commonly at these services there are Specialist Nurses and Physiotherapists skilled in supporting patients with bowel problems like constipation.

They will take a detailed history from you and work with you to manage your symptoms of constipation. Once again, it is a good idea to take your bowel diary with you if you have been completing one.
With a specialist service, it is again usual for them to start with conservative treatment; this can be small lifestyle changes, as well as positioning on the toilet and reviewing a bowel diary. Further options will be discussed as needed, and you will receive advice and support to help you manage the condition.

This article is part of the Education Spotlight on Constipation, supported by Renew Medical. You can also read more about constipation in our information library here.

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Top Tip If you notice any persistent change in your bowel habit, such as needing to go to the toilet more often, having looser stool, bleeding from your bottom or stomach pain please visit your GP, as these symptoms could indicate other problems.

Myth: ‘Normal’ bowel movement means passing stool (pooing) every day.

Fact: How often people pass stool differs from one individual to another. Most people will have a bowel movement between three times a day and three times a week. It is when your bowel movements become less frequent than is usual for you that you may need to consider whether you are constipated.

Myth: My poo is formed of separate hard lumps, and the Bristol stool chart says this is very constipated. But I go to the toilet every day, so I must be OK.

Fact: A normal bowel motion should be well formed, soft and easy to pass. Types 3 and 4 on the Bristol stool chart are normal.

Myth: I have occasional diarrhoea; I can’t be constipated.

Fact: You may experience faecal leakage as a result of constipation – liquid stool can build up behind and then bypass the dry stool.

Myth: Only old people get constipation.

Fact: Constipation does appear to be more common in women and older people but anyone, of any age, can struggle with constipation.

Myth: Constipation is inevitable.

Fact: Constipation is very common, but it can be distressing and uncomfortable. There are a number of changes that can be made that usually improve the condition.

This article is part of the Education Spotlight on Constipation, supported by Renew Medical. You can also read more about constipation in our information library here.

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Top Tip “If you notice any persistent change in your bowel habit, such as needing to go to the toilet more often, having looser stool, bleeding from your bottom or stomach pain please visit your GP, as these symptoms could indicate other problems.”

It’s likely to be constipation if:

• you have not had a bowel movement at least 3 times in a week
• your bowel movements are frequently difficult to complete,
  or larger than usual
• your bowel movements are often dry, hard or lumpy

You may also have a stomach ache and feel bloated or nauseous.

“If there is inadequate fluid intake, then the body will try to hold onto water and one way it does this is by making stools harder.”

What causes constipation?

Constipation in adults has many possible causes. Sometimes there’s no obvious reason.

The most common causes include:

• not eating enough fibre – such as fruit, vegetables and whole grains
• not drinking sufficient fluids
• being less active and not taking frequent exercising
• often ignoring the urge to go to the toilet
• changes in your diet or daily routine
• a side effect of medicine
• stress, anxiety or depression
• during pregnancy and for 6 weeks after child birth

Water helps to keep the stools soft. If there is inadequate fluid intake, then the body will try to hold onto water and one way it does this is by making stools harder. This makes it more difficult for them to move through the bowel.

Fibre helps to bulk up the stools, which makes it easier for the stools to move along the bowel and be passed. If there is not enough fibre stools tend to be smaller and harder. There is information about fibre in the Bladder & Bowel UK information library.

Exercise helps to stimulate the muscles in the bowel wall and helps to move stools on through.

Ignoring the urge to go to the toilet or not responding to the sensation of needing to pass a stool will result in the stool remaining in the bowel longer than it should. This can result in stools becoming harder, drier and more difficult to pass.

 A change in eating patterns or a change in routine, such as a new job or going on holiday.  The bowel can be sensitive to change and just knowing what triggers your constipation can help you to manage the symptoms.

Medications can cause constipation. Some of the most common medications which can cause constipation include:

• Aluminium antacids (medicine to treat indigestion)
• Antidepressants
• Antiepileptics (medicine to treat epilepsy)
• Antipsychotics (medicine to treat schizophrenia, manic conditions and anxiety)
• Calcium supplements
• Diuretics (water tablets)
• Iron supplements

Pregnancy, and the associated changes in hormones, affect the bowel wall muscles and can make them sluggish.

Other conditions that can cause constipation include:

• Neurological conditions including Parkinson’s Disease and Multiple Sclerosis
• Colon or rectal cancer
• Diabetes or Hypercalcaemia (where there is too much calcium in your blood stream)
• Underactive thyroid
• Muscular dystrophy (a genetic condition which causes muscle wasting)
• Spinal cord injury
• Anal fissure (a small tear of the skin just inside the anus)
• Inflammatory bowel disease (a condition that causes the intestines to become inflamed)
• Irritable bowel syndrome (IBS)

Constipation can develop without any of the above issues.  This may be due to the bowel working more slowly (slow transit constipation). It may also be due to difficulties with the pelvic floor. People with learning disabilities are also more prone to constipation. For more information on this see the Bladder & Bowel UK information libraries.

Constipation is more common as we get older because as we age we tend to eat and drink less, become less active or less able to exercise, and have greater difficulty reaching a toilet. We are also more likely to be taking medicines that cause constipation, and have medical conditions that affect the bowel. People in hospital are especially prone to constipation.

Help is available, however. Your GP may refer you to your local Continence Service or Specialist Physiotherapist.  You may be referred to a Gastroenterologist first particularly if you present with a range of symptoms or your bowel habit has changed recently.

This article is part of the Education Spotlight on Constipation, supported by Renew Medical. You can also read more about constipation in our information library here.

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Edited by Emma Cooper, Editor of Pf Magazine.

This blog post examines the causes and diagnosis of opioid-induced constipation (OIC) and addresses effective routes to management for an improved quality of life.

Opioids are extremely effective painkillers that work by binding to receptors in the brain and spinal cord to relieve pain. Opioid-induced constipation (OIC) is part of a group of symptoms, collectively named opioid-induced bowel dysfunction (OIBD), that affect patients taking opioids. Studies suggest that OIC affects between 41% and 57% of patients taking opioids for pain (Cobo et al, 2021), and up to 87% of patients with terminal cancer using opioids (Cobo et al, 2021; Ahmedzai and Boland, 2010). Treating OIC is, however, extremely challenging.

Causes and diagnosis of OIC

As well as being present in the brain and spinal cord, opioid receptors are found in the gut, which means that the opioids can bind to the μ-receptors in the enteric system. When they bind to these receptors, they interfere with the body’s ability to move waste material through the intestines (Poulsen et al, 2015). The opioids inhibit gastric emptying and peristalsis in the gastrointestinal tract, resulting in the delayed absorption of medication and in increased absorption of fluid. The lack of fluid in the intestine leads to hardening of stool and constipation (Coluzzi et al, 2021).

The Rome IV criteria define OIC as ‘new or worsening symptoms of constipation when initiating, changing or increasing opioid therapy’ (Rome Foundation 2016). The criteria also states that these symptoms must include two or more of the following in at least 25% of defecations: straining, lumpy or hard stools, sensation of incomplete evacuation, sensation of anorectal blockage, use of manual manoeuvres to facilitate defecation, and fewer than three spontaneous bowel movements per week. In practice, however, the criteria are underused (Coluzzi et al, 2021).

The impact of OIC

The condition frequently has a negative impact on patients’ quality of life, including their ability to perform daily activities and work productively. They may also experience an increase in depression and anxiety. Some patients reduce or discontinue opioid treatment, preferring to experience the pain rather than the debilitating effects of OIC (Argoff et al, 2020).

OIC also has an economic burden. There is limited information about the cost to the NHS, though we do know that in 2018-19, the estimated annual spend by NHS England on constipation was £168 million (Bowel Interest Group, 2020).

The problem with laxatives

In people with OIC, laxatives are an ineffective treatment, as are bowel regimens, dietary changes, and lifestyle modifications. This is because they do not target the underlying cause – the opioid binding to the μ-receptors in the gastro-intestinal tract (Kumar et al, 2014).

Laxatives can also have unpleasant side effects. In one study of 198 patients taking opioid analgesics for at least one month, 73% had used laxatives at some point. Of these, 75% reported side effects, including gas, bloating or fullness, and a sudden urge to defecate. Approximately half of patients said laxatives interfered with work and social activities, and one fifth needed an overnight hospital stay because of their pain condition and/or constipation. Neither did laxatives improve the symptoms of constipation, as assessed by the Bowel Function Index (Emmanuel et al, 2017).

Using PAMORAs to treat OIC

Peripheral-acting mu opioid receptor antagonists (PAMORAs) are drugs that act directly on the mechanism causing OIC, combining with μ-receptors to inhibit the action of opioids in the gastrointestinal tract. Because PAMORAs reduce the effect of opioids in the gut without affecting how opioids work in the brain and spine, they enable the gastrointestinal system to function normally while maintaining the pain relief functions of opioids.

Addressing the problem

Healthcare professionals are often poorly informed about OIC and continue to treat it with ineffective laxatives rather than PAMORAs. One Italian multidisciplinary panel noted that use of the Rome IV criteria, which propose that OIC should be defined as new or worsening constipation when initiating, changing or increasing opioid therapy, mean that the early diagnosis of faecal stasis may be missed, particularly in older patients and those with cancer, and especially if bedridden (De Giorgio et al, 2021).

The panel also observed that not all specialists agree on the signs and symptoms of OIC specified in the Rome IV criteria, and recommend instead developing a symptom-based definition of OIC that is easy to apply in everyday clinical practice, both in community care settings (e.g. primary care and nursing homes) and in hospitals.

They note that current guidelines ‘do not provide a clear recommendation as to the frequency with which OIC should be evaluated’, and that therefore ‘constipation should be evaluated on a continuous basis in all patients who take an opioid.’

The recommendations made by the panel include proper education about OIC, stating: ‘Physicians of all specialties who treat patients on a long-term opioid, nurses, caregivers, and patients should be instructed about the risks of OIC and strategies for its prevention or treatment.’ The panel also recommends limiting interventions that rely on lifestyle changes or dietary and hydration changes, and that patients should not be left to solve the problem of OIC on their own.

Conclusions

The lack of physician awareness both of the impact of OIC and the appropriate treatments means that patients, many of them already seriously ill, often suffer unnecessarily. It is possible, however, to relieve symptoms through the use of better diagnosis and treatment.

In short, clinicians need to take a more proactive approach in the management of OIC, using a standard, symptom-based definition of OIC; educating themselves about treatment options; asking the patient regularly about symptoms; and making sure that patients receive therapy that manages their pain appropriately while avoiding the debilitating consequences of OIC.

To find out more about the impact of OIC, keep an eye out for the Bowel Interest Group’s latest report, The Cost of Opioid-induced Constipation, which will be published this summer and sets out to educate primary and secondary healthcare professionals in the management of OIC.

References

Ahmedzai, S H, & Boland, J. Constipation in people prescribed opioids. BMJ clinical evidence. 2010; 2407.

Argoff C. E. (2020). Opioid-induced Constipation: A Review of Health-related Quality of Life, Patient Burden, Practical Clinical Considerations, and the Impact of Peripherally Acting μ-Opioid Receptor Antagonists. The Clinical journal of pain, 36(9), 716–722. https://doi.org/10.1097/AJP.0000000000000852

Bowel Interest Group (2020). Cost of constipation report. 2020. Available from: https://bowelinterestgroup.co.uk/resources/cost-of-constipation-report-2020/

Cobo Dols M, Beato Zambrano C, Cabezón-Gutiérrez L, et al. KYONAL study. BMJ Supportive & Palliative Care. 2021 https://doi: 10.1136/bmjspcare-2020-002816

Coluzzi F, Alvaro D, Caraceni AT, Gianni W, Marinangeli F, Massazza G, Pinto C, Varrassi G, Lugoboni F. Common Clinical Practice for Opioid-Induced Constipation: A Physician Survey. J Pain Res. 2021; 14, 2255-2264
https://doi.org/10.2147/JPR.S318564

De Giorgio R, Zucco FM, Chiarioni G, et al. Management of Opioid-Induced Constipation and Bowel Dysfunction: Expert Opinion of an Italian Multidisciplinary Panel. Adv Ther. 2021; 38(7):3589-3621. https://doi: 10.1007/s12325-021-01766-y.

Emmanuel A, Johnson M, McSkimming P, Dickerson S. Laxatives Do Not Improve Symptoms of Opioid-Induced Constipation: Results of a Patient Survey. Pain Med. 2017; 18(10):1932-1940. https://doi: 10.1093/pm/pnw240.

Kumar, L., Barker, C., Emmanuel, A. (2014). Opioid-Induced Constipation: Pathophysiology, Clinical Consequences, and Management, Gastroenterology Research and Practice. 2014. https://doi.org/10.1155/2014/141737

Poulsen, J L, Brock, C, Olesen, A E, Nilsson, M, & Drewes, A M. Evolving paradigms in the treatment of opioid-induced bowel dysfunction. Therapeutic Advances in Gastroenterology. 2015; 360–372. https://doi.org/10.1177/1756283X15589526

Rome Foundation. Appendix A: Rome IV Diagnostic Criteria for FGIDs. 2016. Available at: https://theromefoundation.org/rome-iv/rome-iv-criter

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This post is promoted content by Firefly GottaGo, on behalf of Leckey.

We are all familiar with the squat posture being a great lower body exercise to target quads, hamstrings, glutes and calves. But what about squatting for function?

Some years ago, I spent time in rural Asia and was amazed at how common it was to see people of all ages squatting.  As the squat posture is rarely seen in Ireland, (except by young children and perhaps at the gym), I was fascinated. From cooking to chatting, working to relaxing, squatting was the go-to posture for many activities. That included using the toilet.

A little reading on the topic revealed that the Western raised toilet is a relatively modern invention. Initially adopted by kings and queens, a raised toilet also suited the invention of the U-bend, Therefore, so sitting on the toilet as opposed to squatting gradually became the norm for most of us.  Now, many years later, it is widely recognised within the healthcare community that the squat posture is the healthiest way to pee and poo (see National Institute for Clinical Excellence guidelines).

The link between squatting and toileting function

For me, the subject simmered in the background for some years until a unique opportunity arose for the development of a new supportive toileting seat for children. It was time to do some deeper research. I learnt about the function of the puborectalis muscle, part of the pelvic floor, which wraps around the rectum like an elastic band. This muscle, which is in a constant state of tonic contraction helps to maintain continence when we stand, lie and even sit. To be technical, it pulls the anal canal forward toward the pubis, thus maintaining a sharp angle in the rectum. That is until we squat. When squatting the muscle relaxes and the rectum straightens which lets gravity do the work for us.

Squatting also enables the thighs to put gentle pressure on the abdomen. Research indicates that people who squat report less straining and take less time to go (Sikirov, 2003).  Other studies have shown that adopting a squat position when pooing lowers abdominal pressure, suggesting this position requires less effort for bowel emptying (Tashiro et al, 2020).  A fascinating new study (Garcia-Fernandez and Emanuel Petros, 2020) has demonstrated a positive link between squatting-based exercises and reducing daytime and night-time incontinence in children.

An additional bonus of the squat posture is that it stretches the muscles around the hip joint. Adductor magnus and the proximal hamstrings (both of which are often shortened and tight in children with neurological impairment) along with the erector spinae of the lower back and gluteus maximus.

Assistance with squatting

We know that due to reduced mobility and compounding neurological issues, children with additional needs (such as cerebral palsy) frequently have chronic constipation. Their trunk control – which is linked to abdominal and pelvic control (Talu, 2018) – is often poor and slower to develop. This may cause patterns of incontinence to set in early which may be difficult to shift.  Where this is coupled with low expectations by family, education or healthcare professionals, children will not be supported to reach their potential.

But it does not need to be like this.

The squat posture can stretch tight muscles, reduce straining, and assist natural physiological function. This can promote toilet training success, which will have a positive impact on activity, participation, and quality of life for both the child and the family.  Now there is a child-sized product to support the functional posture of squatting and toileting, there is only question that remains. When are adults going to catch up?

– Dr Laura Finney PhD

This post is promoted content by Firefly GottaGo, on behalf of Leckey.

References

• https://www.nice.org.uk/guidance/cg49/chapter/1-Guidance
• Sikirov, D. Comparison of Straining During Defecation in Three Positions: Results and Implications for Human Health. Dig Dis Sci 48, 1201–1205 (2003). https://doi.org/10.1023/A:1024180319005
• Tashiro, Daisuke & Nakahara, Masami & Kitajima, Eiji & Haraguchi, Kenzo. (2020). The effects of a defecation posture, supported by the upper limbs, on respiratory function. Journal of Physical Therapy Science. 32. 332-336. 10.1589/jpts.32.332.
• Garcia-Fernandez, A. and Emanuel Petros, P. 2020. A four-month squatting-based pelvic exercise regime cures day/night enuresis and bowel dysfunction in children aged 7–11 years. Central European Journal of Urology, 73 (3), pp. 307-314.
• Talu, B. 2018. Determine the Relationship Between Abdominal Muscle Strength, Trunk Control and Urinary Incontinence in Children with Diplegic Cerebral Palsy. Urology Journal, 15 (4), pp. 180-185.

More advice on constipation

Are you concerned that you or someone else may be constipated? Speak to a healthcare professional (GP, school nurse or health visitor) for advice.

Bladder & Bowel UK publish a quarterly e-newsletter, which is full of interesting articles, suggestions and information for people affected by bladder and bowel conditions. To receive the newsletter please send an email to bbuk@disabledliving.co.uk, You can find out more on our newsletters page.

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What we eat can affect our health. Diet is particularly important in the early years of life because childhood is the time of rapid growth and development and lots of activity.  It is also a time when behaviours and habits are learnt that may continue to have an influence into adulthood.

Constipation and diagnosis

What we eat affects our bowels as well as the rest of our body. Constipation is known to affect about 10% of children and if not treated quickly can last for weeks, months or even longer. Although it is most likely to start when children are toddlers, it is known that it can occur in babies, particularly around the time of weaning and in older children as well.  Constipation is not always easy to diagnose in children as there are different symptoms which are not always recognised. Not all children who are constipated pass hard or infrequent poos, which are the things that most families associate with this problem.

Constipation can cause abdominal pain, soiling (where poo leaks into the child’s clothing), poor appetite, poor behaviour, low mood. It can affect school attendance and how well children do with their education. It impacts on the whole family, particularly if there is soiling.

Constipation and poor diet

The belief that constipation is associated with poor diet, particularly a lack of fibre and of not drinking enough water-based drinks is still common. However, research evidence suggests that this may not be the case for most children. While it remains true that healthcare professionals are often unable to find the underlying cause of constipation for many children who have the condition, some studies suggest that constipation may have a genetic element or other causes rather than low fibre intake.

The National Institute for Health and Care Excellence (NICE) produced guidance on constipation in children in 2010. This advice and the research evidence underpinning it has been reviewed several times since, but remains: ‘Do not use dietary interventions alone as first-line treatment’ for constipation in children. This is because NICE found that there was no evidence to suggest that giving children more fibre to eat would, on its own, improve the constipation.

So, what should the advice be for children with constipation and for their families?  Treating constipation in children according to NICE guidance involves use of laxatives as the initial intervention. Usually macrogols are tried first: Cosmocol, Laxido and Movicol are all macrogols that may be prescribed for children. Once the child’s constipation is improving lifestyle advice should also be given. This involves providing information about food, drinks and regular toilet visits to try and poo, usually at least once a day after meals.

Constipation and fluids

Children with constipation should be encouraged to drink the right amount of water-based drinks each day, for their age, size and activity levels. Water is needed by the body and if insufficient is drunk each day, the body will try to retain water where it can. That includes reabsorbing more from the poo, creating drier, harder poos that may contribute to constipation. However, there is no evidence that increasing fluid intake alone will treat constipation in children.

The correct amount of water for children is about 600mls for children aged 7–12 months, 900mls for 1–3 year olds, 1200mls for 4–8 year olds, 1600mls for girls aged 9– 3 years old, 1800mls for boys aged 9–13 years old, 1800mls for girls aged 14–18 years old and 2600mls for boys aged 14–18 years old. If children are very active, overweight or in hot environments they will need more than this.

It is suggested that children with constipation have the same fibre intake as is recommended for their peers. For children aged 2 to 5 year-old this is about 15g of fibre a day; for 5 to 11 year-olds it is about 20g and for 11 to 16 year-olds it is about 25g. Children should get much of their fibre from fruit and vegetables high-fibre bread, baked beans and wholegrain breakfast cereals. Children should not be given unprocessed bran, as this can cause bloating and wind and reduce the absorption of some nutrients in their food.

Rarely constipation in children may be associated with a food intolerance or allergy. The most common of these include an intolerance to dairy products or to gluten. Gluten is a protein found in wheat, barley and rye. However, children should not have dairy products or gluten-containing foods removed from their diet without the advice of a healthcare professional.

More information on constipation in children

If you are concerned that your child may be constipated or have a problem such as an allergy or intolerance to a particular food, do speak to their healthcare professional (GP, school nurse or health visitor) for advice, as constipation can happen in children who already have healthy eating and drinking habits and adjusting diet and fluids alone is unlikely to make the problem better.

There is more information about constipation and its management for children, and on other bladder and bowel conditions experienced in childhood, on the Bladder & Bowel UK website at https://www.bbuk.org.uk/children-young-people/children-resources/.

There is a table with more information about how much fibre is in different foods in the leaflet Understanding Childhood Constipation at https://www.bbuk.org.uk/wp-content/uploads/2020/12/Understanding-Childhood-Constipation-1.pdf

Bladder & Bowel UK publish a quarterly e-newsletter, which is full of interesting articles, suggestions and information for people affected by bladder and bowel conditions. To receive the newsletter please send an email to bbuk@disabledliving.co.uk, You can find out more on our newsletters page.

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For more information about bladder conditions in children visit: https://www.bbuk.org.uk/bladder-resources/.

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