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Pediatric Chronic Constipation, Fecal Incontinence and Motility Problems
Many children experience constipation occasionally, but when constipation lasts for weeks or even months, it can lead to serious issues such as fecal incontinence (loss of bowel control) and problems with motility (slow or abnormal intestinal contractions).
Chronic constipation is also known as idiopathic or functional constipation, meaning constipation that occurs without any identifiable cause. Children with developmental issues such as autism spectrum disorders and ADHD are at a higher risk of developing idiopathic constipation.
There is not any one reason why children develop chronic constipation and there could be several different factors that contribute to the condition. Causes of chronic constipation in children may include one or more of the following:
- When a child decides to hold their bowel movement for a prolonged period of time. This could be due to anxiety, not wanting to interrupt play or not wanting to use a restroom outside of their home.
- A diet low in fluids and fiber rich foods
- Other underlying medical conditions
When children ignore bodily cues to go to the bathroom, their stool becomes hard and backs up into the rectum. Over time, the rectum fills with stool and begins to stretch. At this point the hard stool can be difficult and painful to pass and many children will avoid going to the bathroom. This exacerbates the problem, with waste continuing to back up and the rectum and colon continuing to stretch. The condition can become so severe that it interferes with the ability to feel the urge to go. As a result, many children experience overflow incontinence, which is when soiling and accidents occur.
Symptoms of chronic constipation include:
- Chronic abdominal pain
- Decreased appetite
- Having three or fewer bowel movements per week
- Hard and painful stools
- Straining when trying to go to the bathroom
- Inability to finish a bowel movement, also known as incomplete evacuation
- Inability to pass stool even when you have the urge to go to the bathroom
An accurate diagnosis to figure out what could be causing idiopathic constipation is very important in order to develop the best possible treatment plan. Our gastrointestinal (GI) motility specialists conduct motility studies and the latest diagnostic tests and tools to accurately pinpoint the problem. Motility studies are done to track how a child’s digestive system is functioning as well as identify any issues with potty training or toileting behavior.
Motility testing may include:
- Anorectal manometry
- Colonic manometry
If it is determined that there are no underlying serious medical or anatomical problems associated with the cause of the constipation, your child will likely begin pediatric chronic constipation treatment in our Bowel Management Program. Our Bowel Management Program is a comprehensive program that addresses all of the behavioral and/or medical issues that are contributing to the problem. Children are seen daily for an intensive week of outpatient therapy and then at about three and twelve months. Enemas or laxatives may be given to ensure your child has a clean bowel before treatment begins.
Treatment for chronic constipation through the Bowel Management Program includes:
- Establishing a bathroom schedule (based around the gastrocolic reflux) to train your child to recognize their body cues
- Setting up a reward system to encourage your child to go
- Working with nutritionists who help create recipes and diet plans rich in fiber. Our nutritionists have an understanding of how to work with picky eaters, and can offer helpful tips for increasing daily fiber intake.
- If needed, medications such as laxatives may be given to soften stool or help to relax the rectal muscles. For children who have sensory problems or have difficulty swallowing pills, alternatives are suggested to assist parents with administering medications successfully.
- Enemas are sometimes chosen to help empty the bowels regularly.
A nurse practitioner and child psychologist work closely with families to monitor your child’s progress and make adjustments to the treatment plan when needed. Depending on your child’s age and the severity of their condition, their time in the program will vary. In general children who are potty training will see positive results within four months, for school-aged children success may require six months to a year. It is very important to closely follow the treatment plan in order to get the best possible outcome and improve the quality of your child’s life.
Children with certain medical problems that are causing their chronic constipation such as anorectal malformations, Hirschprung disease, colonic dysmotility or spinal disorders may require surgery. Our colorectal surgeons are highly experienced, having performed over 10,000 surgeries for pediatric colorectal disorders.
Surgery performed for chronic constipation include:
A Malone appendicostomy (MACE) is a procedure where a surgeon connects the appendix to the abdomen, making a pathway from the belly button to the colon using laparoscopic techniques. This pathway works as a valve where a catheter is inserted. A special solution is administered through the catheter to clean out your child’s colon each day. No artificial implants or devices are used because the valve has been created with your child’s own tissue. Following a MACE, your child will spend about two days in the hospital and require follow up visits with your surgeon at one month to ensure they are healing properly.
A colon resection may be performed to remove diseased areas of the bowel that may be causing your child’s chronic constipation. This may include any area of the large intestine or rectum. The type of resection your child may need will depend on the severity of their specific condition. The surgery is performed using non-invasive techniques and is guided by the motility evaluation which maps which parts of the colon are working. Your child will typically spend one week in the hospital following a bowel resection and require a follow up visit at one month to ensure that your child has healed properly and to check for any possible complications.
If your child has had a MACE procedure, a catheter will remain in place for one month. To keep the opening from closing once the catheter is removed, a type of plug called an ACE stopper will be put in its place for six months. The plug will be removed once daily to irrigate and flush the colon with a special solution.
How to Care for Your Child’s Malone Appendicostomy
Your child’s medical team will give you detailed instructions on how to care for your child’s Malone surgery site once you are home. Keep in mind that drainage is normal, and may resemble a clear to light yellow color. You will need to administer enema fluid daily through the catheter to keep the colon flushed and clean. For the first month, you should keep the Malone tube secured to your child’s abdomen (with clear tape dressing) without completely covering the opening. It is safe to shower and bathe after surgery. Make sure to clean around the tube insertion with soap and water and then pat dry.
You should call your child’s provider if you notice the following:
- Abdominal swelling or pain during or after flushing the colon
- If the area or stitches holding the catheter in place becomes red and irritated
- The tube falls out prior to your child’s follow-up visit
The Division of Pediatric Colorectal and Pelvic Reconstructive Surgery offers the latest advancements in diagnosis and treatment for all types of pediatric colorectal disorders.
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