J. asks about her 10-year-old daughter’s constipation:

My 10 year old daughter suffers from severe constipation. She has suffered for almost a year and a half now. We have been to the pediatrician many many times and don’t get too much help. They performed an X-Ray and found that her “whole system” was “stuffed from top to bottom”. We were told to give her mineral oil 3 teaspoons a day I believe, and she took the whole bottle without results. She has positive results with 1 adult laxative, but I am afraid of creating a dependence, that will make it impossible for her to go without one. I’ ve read about encropesis, anxiety’s role in cronic sever constipation, and other diseases/disorders. I guess my question is complex, but do you have any additional references (aside from google groups & WebMd) or suggestions. The pediatricians don’t seem to have any more advice to give other than : Take this kind of laxative and retrain her on the potty. Also, is it “normal” for people to void two or three days apart, or should we push for every day?

Dr. Joshua’s answer:

Since your daughter has been examined by pediatricians, I assume that the proper investigations have been done to rule out any serious underlying cause, and as I am not a pediatrician, I doubt that I can add much to what the pediatricians have said. You seem to be well read on the subject, and do not give much detail about the problem.

I can answer your specific question though (as should your pediatrician): There are many patterns of “normal”. A bowel movement 2-3 days apart can be normal. Frequency is not the main issue: whether your child can pass stools easily or not is the main consideration. If there is pain or considerable strain involved, then we may have a problem. Encopresis (staining) is frequently present with constipation.

The psychology of childhood constipation is tricky. I’m not going to delve into the psychoanalytical hoopla, as I am not too enthusiastic about it myself. However, there are obviously social and psychological aspects of childhood constipation which need to be taken into account. I think the main (and quite a common-sense) psychological consideration is fear of pain: if the bowel movements are infrequent, the stool may be hard, and of a large mass, voiding will become painful, and the child may start fearing the pain and consequently will try to hold the next bowel movement for as long as possible. This is a type of vicious circle, which if present needs to be stopped somehow.

Constipation is common in children. Usually it should not be a cause for concern, and will eventually resolve by itself. Various risk factors may be present and should be treated: Emotional stress, psychiatric illness, drugs (i.e. anticholinergics, antidepressants, painkillers..), anal fissures, dehydration, and low-fibre diet are among them.

Rarely, constipation can be caused by a serious illness, such as hypothyroidism, diabetes, spinal cord disorders, toxic substances (such as lead), etc.

Treatment options include increased fluid and fiber intake, stool softeners (mineral oil), oral laxatives, glycerine suppositories, psychological treatment, and enemas.

If you are worried about the psychological side, may I suggest a visit to a pediatric psychiatrist with your daughter? A child psychiatrist is better qualified than a psychologist when a somatic problem such as constipation is present.

Dr. Joshua