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Q:  hi paediatrician. my son is now already 3 yrs old – having chronic constipation since 6 months old.. already done investigation including rectal biopsy – all normal.. very difficult for toilet training as mom working hehehhe… diet pun susah.. heard that probiotics can help for habitual constipation and which brand is the best? what is ur advice? now dependent on syr lactulose. ( Noor Suria )

A:  Hello there Noor, constipation in children is pretty common. In fact, it is one of the most common complaint I encounter in clinic. I understand it must be rather frustrating, especially when your child has had this for a very long time. It seem that all the necessary work up has been done to rule out pathological causes. Therefore, the likely reason for his condition is ‘functional constipation’.

For the benefit of other readers, constipation is defined as having less than 3 complete bowel movement a week and the stool are often hard. The child often finds it difficult to pass motion and he/she often strain at stool.Sometimes, there may even be some bleeding.

In your child’s case, it seem that you have tried diet modification which I assumed includes lots of fibre and water. It is also important that this needs to be coupled with lots of exercise. The NICE (UK) Guideline recommends physical activity for at least one hour a day , and I believe being a 3 year old boy, your child probably has done  tripple or more  of the recommended hour ! : )

consti

Anyway, it is important to realize that kids with chronic constipation has stool retention and often withold their stool as well and as a result constipation continue as a vicious cycle. I’m assuming that he has been assessed for fecal impaction.

It is imperative that your child  feel that passing motion is not painful or else he would continue to withold his stools as he fear the pain that it causes and the constipation becomes a never-ending story. Hence I would often advise parents to continue laxatives e.g lactulose  as maintenance therapy for some time with the aim of producing soft, painless stool to prevent reaccumulation of feces. With time, the child forgets his ‘painful experience of passing hard stool’ and would stop witholding it , thus potty training becomes a lot easier.

The other important aspects of treating constipation is behavioural intervention. This includes scheduled toileting and the use of rewards and encouragement system. It works best when coupled with other interventions because that alone wont help.

I wonder if your child drinks a lot of milk because that too can be a contributing factor. In certain severe cases, cow’s milk exclusion diet helps for those who do not respond to adequate medical and behavioural management, but often with advice of the attending paediatrician.

Probiotics

Anyway, back to your questions on Probiotics. Probiotic is food or oral supplement that contains sufficient number of viable micro-organism to alter the microflora of the host for health benefits. It is available in infant formula, yogurt and oral supplements. A point to remember is that there is a wide variations in potency and quality, and that not all strains of probiotic bacteria are effective for treating constipation . Although, the effectiveness of probiotics on gastroenteritis and antibiotic associated diarrhoea have been established, there is inconsistent data on the effectiveness  in children with constipation. Having said that, I personally feel that it is worth trying but find one that contains different strains of probiotics. You may ask the pharmacist for multiple strains probiotics (due to conflict of interest, i am unable to name the brand). Alternatively, you may want to try giving yogurt twice a day and see if that helps.

The objective is to treat constipation and prevent it from recurring. Therefore, the combination of all these is important.  Hope you find this helpful. Cheers!

( Answered by Dr Zahilah Filzah )

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