Childhood constipation and how pelvic physiotherapy can help
How common is childhood constipation?
Constipation is a growing health problem in North America and data suggests that the incidence of constipation is on the rise. Between 1992 and 2004, data showed that the diagnosis of constipation doubled in outpatient clinics and quadrupled in hospitals. Up to 30% of children between the ages of 2-10 years are chronically constipated. It is the principal complaint in 3-5% of all pediatric outpatient clinics and accounts for up to 25% of visits to pediatric gastroenterologists.
What does it mean for a child to be constipated?
Functional constipation has been defined by the ROME III Classification as; 2 or more of the following features in a child with a developmental age of at least 4 years and occurring at least once per week for at least 2 months.
-2 or fewer defecations in the toilet per week
-at least 1 episode of fecal incontinence per week
-stool withholding behaviour
-history of painful or hard bowel movements
-presence of a large fecal mass in the rectum
-passage of large stools that may obstruct the toilet
What are the symptoms I should be looking for in my child?
Infrequent Stools: Generally, for toddlers and pre-schoolers, bowel movements can occur anywhere from 3 times per day to 3 times per week. It is important to consider the frequency along with the consistency of the stool that is produced to get the whole picture. Be sure to have a good long look at your child’s stool in the toilet before you flush! Comparing it with the Bristol Stool Chart below is an excellent guide to assess whether or not your child’s stool is the right consistency to promote easier and smoother emptying of their bowels. The goal is to avoid stool that is hard, pebble-like or formed with lots of cracks on the surface (Type 1 and Type 2) as this is a signal that your child is constipated. Type 4 or 5 is the ideal consistency of stool.
Pain: Your child may scream out, cry, hold their breath, get red in the face or complain of abdominal pain just before, during or after a bowel movement.
Soiling: There is a 90% association of constipation with children that involuntarily empty their bowels or show stool marks in their underwear. The rectum can be so full of a hard mass of feces that the stool from above leaks around it (encopresis). Sometimes these symptoms are confused with a child having diarrhea.
Stool withholding behaviours: Some toddlers and pre-schoolers may have a serious FOMO (fear of missing out). When nature calls, children may ignore the urge or try everything they can to make it subside if it means they can stay with their friends a little while longer. Alternatively, they may have had a painful bowel movement in the past and are trying to avoid this unpleasant experience again. They may stand on their toes, stretch their legs, rock back and forth, sit on their heels, or even hide somewhere. The longer the stool stays in the rectum, the more water is absorbed from it and the harder and larger the stool becomes. Thus begins the vicious cycle of stool retention and painful bowel movements.
Blood in stools: Large, hard stools are painful to pass as they excessively stretch the rectal muscles and can cause anal fissuring. This may result in blood passed with the stool or found on the toilet paper after wiping.
Urinary incontinence/betwetting: When the rectum is stretched out with compacted, hard stool, this takes up space in the pelvic cavity. This space encroaches upon the bladder which is close by and prevents the bladder from properly expanding and filling itself. The distended rectum can irritate the bladder and give the child a feeling that he or she has to urinate sooner and more frequently than normal.
How can Pelvic Health Physiotherapy help my child?
It is of primary importance that you first discuss your concerns with your child’s paediatrician and/or gastroenterologist as constipation is best resolved using a multi-modal approach. Further investigations may be warranted and a course of medications, such as laxatives, may be integrated into your child’s care for some time to help keep your child’s stool soft and avoid exacerbating the condition. Over time, constipation can significantly affect the flexibility, coordination and strength of your child’s pelvic floor muscles. Your child’s treatment will consist of the following:
1) Education: Treatments focus on educating you and your child to understand the relationship between the bowels and the pelvic floor muscles. We discuss ways to optimize your child’s toileting strategies and postures. Changes in lifestyle, dietary and hydration patterns will be discussed to promote movement of stool through the colon and keep it soft. Your child will be educated on ways to increase his/her awareness of the body’s signals for when it is time to go to the bathroom.
2) Assessment of pelvic floor function: The pelvic floor muscles surround the rectum like a sling. These muscles contract and relax to allow your child to voluntarily close the rectum to delay or prevent defecation. Relaxation of these muscles allows the rectum to open and initiate emptying of the bowels. With persistent constipation, the pelvic floor muscles may become weakened, experience reduced sensation, and lose their coordination and contract when they are supposed to relax (called ‘dyssynergia’). Pelvic floor physiotherapists are able to identify these problems and can help your child retrain these muscles so that they are stronger, more flexible and are properly coordinated during a bowel movement.
What methods do you use to assess my child’s pelvic floor function?
Typically, pelvic floor treatment for children does not entail and internal vaginal or rectal assessment. If appropriate, pelvic floor muscle function may be observed visually, or the physiotherapist may use light touch on the outside surface of the rectum (buttocks around the anal region) to feel the pelvic floor muscles contract and relax. In certain instances, a biofeedback machine may be used through the use of electrode stickers that are placed near the rectum. Biofeedback is able to sense and visually display the electrical conductivity of the pelvic floor muscles when your child is cued to contract or relax the pelvic floor. Whatever the physiotherapist feels is the best method for assessing pelvic floor function, it will be explained, in detail, to you and your child in order to ensure both your child’s safety and comfort throughout treatment.
3) Exercise: Pelvic floor physiotherapy’s goal is to provide your child with fun and interesting exercises that enhance overall body strength and flexibility. These global exercises are also able to tap into the pelvic floor system by optimizing their alignment and ‘readiness’ for function.
Our specially trained pediatric pelvic floor physiotherapists approach each child’s story with sensitivity and patience. Pelvic floor physiotherapy aims to optimize your child’s bowel habits, thereby providing a foundation for pelvic health success throughout your child’ life and well into adulthood.
Hodges, Steve J. Schlosberg, S. (2012) It’s No Accident: Breakthrough Solutions to Your Child’s Wetting, Constipation, UTIs, and Other Potty Problems. Guilford, Connecticut: Lyons Press.