FUNCTIONAL CONSTIPATION IN CHILDREN

EPIDEMIOLOGY

Constipation affects up to 30 percent of children and accounting for an estimated 3 to 5 percent of all visits to pediatricians.⁽¹⁾ Functional constipation is responsible for more than 95 percent of cases of constipation in healthy children one year and older, and is particularly common among preschool-age children.⁽²⁾Prevalence of 12 to 19 percent (average 15 percent) has been reported in most studies.^(3,4). Prevalence rates have been lower in studies using Rome II criteria to define constipation compared with studies based upon self-reporting. Unfortunately, prevalence data of Pakistan on this is lacking.

PATHOPHYSIOLOGY:

Most children suffering from constipation have no underlying medical condition. They are often labeled as having functional constipation or acquired megacolon. In most cases, childhood constipation develops when the child begins to associate pain with defecation. Once pain is associated with the passage of bowel movements, the child begins to withhold stools in an attempt to avoid discomfort. As stool withholding continues, the rectum gradually accommodates, and the normal urge to defecate gradually disappears. The infrequent passage of very large and hard stools reinforces the child's association of pain with defecation, resulting in worsening stool retention and progressively more abnormal defecation dynamics with anal sphincter spasm. Chronic rectal distention ultimately results in both loss of rectal sensitivity, and loss of the urge to defecate, which can lead to fecal incontinence (i.e. encopresis).⁽⁵⁾

Constipation may originate primarily from within the colon and rectum or may originate externally. Processes involved in constipation originating from the colon or rectum include the following:

• Colon obstruction (neoplasm, volvulus, stricture)
• Slow colonic motility, particularly in patients with a history of chronic laxative abuse
• Outlet obstruction (anatomic or functional) - Anatomic outlet obstruction may derive from intussusception of the anterior wall of the rectum on straining, rectal prolapse, and rectocele; functional outlet obstruction may derive from puborectalis or external sphincter spasm when bearing down, short-segment Hirschsprung disease, and damage to the pudendal nerve, typically related to chronic straining or vaginal delivery
• Hirschsprung disease in children
• Chagas disease

Factors involved in constipation originating outside the colon include poor dietary habit (the most common factor, generally involving inadequate fiber or fluid intake and / or overuse of caffeine or alcohol), medications, systemic endocrine or neurologic diseases, and psychological issues.

Constipation results in various degrees of subjective symptoms and is associated with abnormalities (e.g. colonic diverticular disease, hemorrhoidal disease, anal fissures) that occur secondary to an increase in colonic luminal pressure and intravascular pressure in the hemorrhoidal venous cushions.⁽⁶⁾

NATURAL HISTORY:

Constipation is a symptom rather than a disease and, despite its frequency, often remains unrecognized until the patient develops sequelae, such as anorectal disorders or diverticular disease.

No widely accepted clinically useful definition of constipation exists. Health care providers usually use the frequency of bowel movements (i.e. less than 3 bowel movements per week) to define constipation.⁽⁶⁾ However, the Rome criteria, initially introduced in 1988 and subsequently modified thrice to yield the Rome IV criteria, have become the research-standard definition of constipation.

SIGNS AND SYMPTOMS:

SOILING: Children with fecal incontinence most commonly present with repeated soiling of their underwear. Parents may mistake this type of soiling for diarrhea, although its link to chronic constipation has become increasingly recognized.⁽⁷⁾ The child frequently denies both the visible and olfactory signs of soiling of their underwear. The child may appear oblivious or nonchalant about the problem even though it may be a source of considerable embarrassment and confusion for the child, frustration for the parents, and a cause of social stigmatization among peers. In some cases, the episodes appear to be triggered by emotional stress; this is somewhat more likely in the nonretentive form of fecal incontinence.

ABDOMINAL PAIN: Other symptoms may coexist with fecal incontinence. In one series, more than one-half of children had abdominal pain ranging in quality from vague chronic discomfort to severe attacks several days before a large bowel movement or even daily.

DISORDERED URINATION: Disordered urination is also common.^(9,10) In one report, 29 percent of children had daytime wetting and 34 percent had nighttime wetting, while 33 percent of girls and 3 percent of boys had urinary tract infections.⁽⁹⁾

Other Symptoms may include:

• Three or fewer bowel movements per week
• Bowel movements that are hard, dry and difficult to pass
• Large-diameter stools that may obstruct the toilet
• Blood on the surface of hard stool

DIAGNOSTIC TEST:

Diagnostic criteria: A Multinational Working Team developed criteria for functional gastrointestinal disorders known as the "Rome IV" criteria which describes functional constipation as persistently difficult, infrequent, or seemingly incomplete defecation, without evidence of a primary anatomic or biochemical cause. "Rome IV" diagnostic criteria require at least two of six symptoms describing stool frequency, hardness, size, fecal incontinence, or volitional stool retention, with the stipulation that organic causes of constipation are excluded by a thorough evaluation.^(14,15)

ROME IV CRITERIA FOR THE DIAGNOSIS OF FUNCTIONAL CONSTIPATION IN CHILDREN:^(14,15)

Infants and toddlers up to 4 years old Children with developmental age of at least 4 years At least two of the following present for at least one month At least two of the following present at least once per week for at least one month* Two or fewer defecations per week        Two or fewer defecations in the toilet per week History of excessive stool retention At least one episode of fecal incontinence per week History of painful or hard bowel movements History of retentive posturing or excessive volitional stool retention History of large-diameter stools History of painful or hard bowel movements Presence of a large fecal mass in the rectum Presence of a large fecal mass in the rectum In toilet-trained children, the following additional criteria may be used: History of large-diameter stools that may obstruct the toilet At least one episode/week of incontinence after the acquisition of toileting skills The symptoms cannot be fully explained by another medical condition. History of large-diameter stools that may obstruct the toilet

* In addition, the symptoms are insufficient to fulfill the diagnostic criteria of irritable bowel syndrome.

EXCLUSION OF ORGANIC CAUSES: The diagnosis of functional constipation also requires exclusion of organic causes of the symptom. Particular attention should be paid to the following causes, which are relatively common or require urgent diagnosis:

• Common organic causes – Cow's milk (or other dietary protein) intolerance; celiac disease; hypothyroidism
• Urgent causes
• Infants – Hirschsprung disease, spinal dysraphism, sacral teratoma, infantile botulism
• All ages – Cystic fibrosis, lead poisoning, intestinal obstruction

HISTORY: History is often helpful in discriminating functional constipation from Hirschsprung disease. Asking parents when their child passed his or her first bowel movement after birth is particularly important. Most children with Hirschsprung disease have difficulties with constipation dating to birth or shortly after birth. Asking about a history of fecal incontinence or soiling is also important as many parents confuse fecal soiling (i.e. encopresis) with poor hygiene or chronic or recurrent diarrhea.

Most cases of chronic childhood constipation are precipitated by painful bowel movements with resultant voluntary withholding of stool.⁽¹¹⁾

PHYSICAL EXAMINATION: The physical examination should include an evaluation of the perianal area, including the appearance and location of the anus, and sensory and motor function. A digital rectal examination is included for selected cases:⁽¹²⁾

EXTERNAL EXAMINATION:

• General: The general physical examination should include assessment of growth and abdominal distension, and abdominal or pelvic masses. It should specifically evaluate for features of spinal dysraphism, which has clinical manifestations ranging from benign or asymptomatic to severe neurologic, genitourinary, gastrointestinal, or musculoskeletal anomalies. Occult spinal dysraphism is suggested by increased pigmentation, vascular nevi, or hair tufts in the sacrococcygeal area.
• Neurologic: The neurologic evaluation of children with chronic constipation should focus on symptoms and signs suggesting spinal cord and / or autonomic nervous system dysfunction, including:
• Sensory loss or motor weakness
• Abnormal muscle tone
• Abnormal deep tendon reflexes
• A patulous anus
• An absent cremasteric reflex
• Associated bladder dysfunction
• Perineum: The perineum should be inspected for abnormalities of anorectal development, which represent a spectrum from high imperforate anus to anteriorly displaced anu.⁽¹³⁾

DIGITAL ANORECTAL EXAMINATION: A digital anorectal examination is not routinely necessary for the evaluation of patients with a typical history and symptoms of functional constipation. This is because the digital anorectal examination is unpleasant for the child and has only moderate sensitivity and specificity for detecting or confirming constipation in this group of patients.⁽¹²⁾ However, some providers perform a digital examination in selected cases of suspected functional constipation. The goals of the examination are to detect a fecal impaction, which would require a "cleanout" approach (initiation of treatment with high doses of laxatives and / or enemas), and to detect occult blood, which would require further diagnostic testing.

A digital examination is suggested for the following groups of patients:⁽¹²⁾

• Infants with constipation
• Children with symptoms since early infancy
• Infants or children with other alarm signs that suggest organic disease
• Children in whom the presence or degree of constipation is unclear (eg, meeting only one Rome IV criterion)

Findings suggestive of functional constipation are a distended rectum that is full of stool. However, lack of stool does not exclude the possibility of functional constipation.

FURTHER TESTING: In most cases, organic causes of constipation can be excluded on the basis of a careful history and physical examination. If warning signs of possible organic constipation are present, focused laboratory and radiographic testing should be performed. In addition, these tests may be appropriate for patients who fail to respond to a well-conceived and carefully administered intervention program, including disimpaction, frequent and effective use of laxatives, and behavioral management.

IMAGING:

• Abdominal radiograph: A plain abdominal radiograph is not indicated for the routine evaluation of functional constipation.⁽¹²⁾ However, it can be helpful to document retained stool when there is inadequate historical information to determine if the patient has constipation or if the physical examination is limited by patient cooperation, obesity, or is deferred for psychological considerations.
• Rectal Biopsy: Rectal biopsy is the definitive means of establishing or excluding Hirschsprung disease. This procedure is usually unnecessary when the clinical picture and the radiologic findings are characteristic of idiopathic constipation. The tissue is examined histologically for the presence or absence of ganglion cells in the submucosal plexus. If the patient's rectum has no ganglion cells, the diagnosis of Hirschsprung disease is confirmed.
• Barium enema: A barium enema provides supportive evidence for Hirschsprung disease in children with features suggestive of this disorder, such as early onset constipation from the neonatal period, especially with delayed passage of meconium, or suggestive findings on anorectal examination. Some providers use anorectal manometry as the initial investigation or proceed directly to rectal biopsy. In very young infants, the barium enema may be normal and the diagnosis must be established by rectal biopsy.
• Spine radiographs: Plain films of the lumbosacral spine should be performed for children with evidence of spinal dysraphism or neurological impairment of the perianal area or lower extremities. If there is a high suspicion of neurologic dysfunction, magnetic resonance imaging (MRI) should be considered to investigate the possibility of tethered cord and spinal cord tumors.^(12,16,17)

LABORATORY TESTS:

It is suggested to perform following laboratory testing at the time of the initial evaluation in patients with signs or symptoms suggestive of an organic cause of constipation, such as the following clinical situations:

• Celiac screening: For children with failure to thrive or recurrent abdominal pain, perform a complete blood count and serologic screening for celiac disease (usually IgA antibodies to tissue transglutaminase).
• Urine analysis and culture: For children with a history of rectosigmoid impaction, especially in association with encopresis,^(9,18,19) perform a urine analysis and urine culture. This is because fecal impaction may predispose to urinary tract infections due to the mechanical effects of the distended rectum compressing the bladder.
• Thyroid stimulating hormone: For children with impaired linear growth and depressed reflexes, or those with a history of central nervous system disease, screening for hypothyroidism is suggested.
• Electrolytes and calcium: For children at risk for electrolyte disturbances (e.g. those with metabolic abnormalities or inability to tolerate adequate fluids), we suggest measuring serum concentrations of electrolytes and calcium.
• Blood lead level: Screening for lead toxicity should be performed in children with risk factors.

This list is not exhaustive and specific laboratory testing may be considered in any patient with an atypical presentation.

MOTILITY TESTING:

Motility testing is typically considered in patients who have no obvious organic cause of constipation and who fail to respond to vigorous treatment of functional constipation.

COLON TRANSIT STUDIES: A colonic transit study is not helpful for the routine evaluation of a child with constipation because the results rarely alter management.⁽¹²⁾ This study is generally reserved for the secondary evaluation of selected patients in whom the diagnosis is unclear despite a thorough initial evaluation and trials of treatment. In particular, it may be useful for the following purposes:⁽²⁰⁾

• To help distinguish between retentive fecal incontinence (constipation-associated) and non-retentive fecal incontinence.⁽¹²⁾
• To identify children with abnormally slow movement of food residue through the colon, a condition referred to as "slow-transit" constipation.
• To identify children with stool expulsion disorders, suggesting outlet obstruction.

ANORECTAL MANOMETRY: Anorectal manometry involves placement of a catheter containing pressure-transducing sensors into the rectum, thereby permitting measurement of neuromuscular function of the anorectum. The procedure includes measurements of the rectoanal inhibitory reflex (which is absent in Hirschsprung disease), rectal sensation and compliance, and squeeze pressures. The test is performed mainly in children with intractable constipation that restricts their lifestyle, or when there is suspicion of internal anal sphincter achalasia, or Hirschsprung disease.^(18,2-24)

TREATMENT OPTIONS:

Treatment of chronic functional constipation and fecal incontinence typically requires a comprehensive program, including the use of laxatives, behavior changes, and dietary changes.

PARENTAL EDUCATION: Effective education of the parents and child with regard to constipation is crucial in changing chronic behavior patterns.^(12,25) The parent or caretaker must understand that soiling due to overflow incontinence does not constitute willful and defiant behavior by the child but represents physiologic loss of continence. The child should therefore not be scolded, or otherwise punished, for soiling episodes.^(26,27) In toddlers with constipation, toilet training should be postponed since it will not be successful until rectal awareness is restored and defecation is pain free.⁽¹⁸⁾

DISIMPACTION: "Fecal impaction" is a term used to describe markedly increased amounts of stool in the colon, which is a subjective judgement based on clinical findings.

The majority of children who come to medical attention because of chronic constipation have fecal impaction, and will benefit from a regimen to disimpact the rectum before beginning maintenance therapy.^(12,25,27) Disimpaction step is suggested  for children with any of the following characteristics:

• Constipation-associated fecal incontinence
• Significant stool mass palpable on digital rectal or abdominal examination, or on abdominal radiograph
• History of incomplete or infrequent evacuation

Disimpaction and catharsis can be effectively accomplished with oral or nasogastric medications, rectal medications, or a combination. It is important to assess the response to the regimen as soon as possible after it is completed. Successful disimpaction is usually indicated by abundant fecal production and decreased episodes of soiling, as reported by the parents.⁽²⁵⁾

ORAL MEDICATIONS:: For children with fecal impaction, oral medications for disimpaction is generally suggested because this method is noninvasive and may help the child feel in control.⁽¹²⁾

Polyethylene glycol (PEG) without electrolytes, PEG-electrolyte solutions, or high-dose mineral oil have all been shown to be effective for initial disimpaction.^(28-34) The PEG without electrolytes is generally the most palatable of these options and better accepted by children.⁽¹²⁾ The doses are as follows:

• Polyethylene glycol 3350: 1 to 1.5 g / kg / day by mouth for up to six days. The daily dose is dissolved in approximately 10 mL / kg of water or flavored beverage. For patients with inadequate disimpaction using six days of PEG-based treatment at home, rectal medications or PEG-electrolyte cleanout in the hospital should be considered.
• Polyethylene glycol-electrolyte solution: 25 mL / kg per hour to a maximum of 1000 mL / hr by nasogastric tube until stool appears clear, or 20 mL / kg per hour for four hours per day.⁽³⁰⁾ Nasogastric administration is suggested because most children are not able to take sufficient quantities of this solution by mouth.
• Mineral oil: 15 to 30 mL per year of age, up to 240 mL per day by mouth. Mineral oil should not be used for infants, neurologically impaired children, and others at high risk for gastroesophageal reflux, because of risks of pneumonitis if the oil is aspirated.^(35,36)

Other oral agents that have been used successfully for disimpaction, but for which controlled trials are lacking, include magnesium hydroxide,⁽³⁷⁾ magnesium citrate,⁽³⁸⁾ lactulose,⁽³⁹⁾ sorbitol, senna, and bisacodyl.⁽³⁷⁾

RECTAL MEDICATIONS: For patients with severe impaction, rectally administered medications is preferred rather than oral medications because stimulants can cause intense discomfort and may not be effective in this setting.

Sodium phosphate enemas, or mineral oil enemas followed by a sodium phosphate enema may be used for rectal disimpaction.^(12,18) The doses are as follows:

• Sodium phosphate enema:13 ounce (33 mL) enema for children 2 to <5 years; 2.25 ounce (66 mL) enema for children 5 to 12 years; and 4.5 ounce (133 mL) enema for children ≥12 years. These enemas should not be used in children younger than two years of age. This dose may be repeated once within 12 to 24 hours, if necessary. More frequent dosing should be avoided because there are several case reports of life-threatening hyperphosphatemia and hypocalcemic tetany, particularly in young children, those with colonic dysmotility, and / or with repeated administration of enemas.^(40-43)
• Saline enema: This can be administered using a dose of 10 to 15 mL per kg.
• Mineral oil enema:25 ounce (66 mL) enema for children 2 to 12 years of age, and 4.5 ounce (133 mL) enema for children ≥12 years.

Bisacodyl suppositories may be used for older children, and glycerin suppositories for infants.^(12,44) These approaches are generally not as effective as enemas but are well tolerated.

ORAL AND RECTAL: Combination treatment with oral and rectal medications is often the most effective approach for moderate or severe fecal impaction. In this case, the initial treatment is with oral medication to soften the stool, and rectal medication is added on day two to help evacuate the impacted stool. An alternative combination approach consists of three to four consecutive three-day cycles in which a phosphate sodium enema is administered on day one, a bisacodyl suppository on day two, and bisacodyl tablet (10 mg) on day three.^(25,45)

LAXATIVES: After disimpaction, patients should be treated with a maintenance regimen of oral laxatives to "retrain" the bowel and avoid reimpaction, which could restart the constipation cycle. Adequate doses of medication should be given to maintain a pattern of soft bowel movements once or twice a day. It is important to start this maintenance regimen of laxatives immediately after disimpaction to avoid reaccumulation of stools.

The laxatives that are considered safe and are used most often for children include polyethylene glycol 3350, magnesium hydroxide (milk of magnesia), lactulose, and mineral oil.

POLYETHYLENE GLYCOL: PEG without electrolytes (polyethylene glycol 3350) is an osmotic laxative. Because it is more palatable and has fewer adverse effects than other agents, PEG without electrolytes is preferred by most experts for disimpaction and treatment of chronic constipation, although it is not yet labeled for this use.⁽¹²⁾

MINERAL OIL: Mineral oil is a lubricant laxative that was the mainstay of therapy for chronic constipation and fecal incontinence in the past. It has largely been replaced by osmotic laxatives, which are more palatable and easier to administer, and are at least as effective as mineral oil.

MAGNESIUM HYDROXIDE: Magnesium hydroxide (milk of magnesia) is an osmotic laxative that has a long history of success but has been largely replaced by PEG because of palatability, and possibly lower efficacy.⁽⁴⁶⁾

LACTULOSE: Lactulose is an osmotic laxative and is usually well tolerated in the long-term.⁽¹²⁾ Lactulose is not absorbed by the small intestine. Side effects include flatulence and abdominal cramps, which occur when the sugar is metabolized by colonic flora.

STIMULANT LAXATIVES: Stimulant laxatives, such as senna and bisacodyl, are sometimes used for brief periods to avoid recurrence of impaction ("rescue" therapy), and their use for this purpose is supported by extensive clinical experience and expert guidelines,⁽¹²⁾ although controlled trials on the use of these agents for constipation in children are lacking.⁽⁴⁷⁾ Stimulant laxatives also may be helpful for patients with anorectal malformations or other disorders that affect anorectal innervation, which can affect sensory and motor function and predispose to both constipation and fecal incontinence.⁽⁴⁸⁾

DIETARY CHANGES:

During the treatment of fecal incontinence and / or chronic constipation, it is important to ingest a diet that is conducive to fecal regularity.^(12,25) Increased intake of fruit and raw vegetables, bran, and whole-grain breads and cereals is commonly recommended, as is adequate intake of fluids other than milk.

• Fiber: Increasing the intake of fiber, through dietary changes or fiber supplements, is often recommended for acute and chronic constipation. However, the evidence base for this practice is weak and somewhat conflicting.⁽¹²⁾ This may be because dietary fiber can have either beneficial or adverse effects in children with constipation, especially in the setting of chronic constipation and recurrent impactions. On the one hand, fiber adds bulk and water content to the stool; this can make the stool softer and easier to release. On the other hand, the increased stool bulk also may cause greater distension of the rectum and colon in children with fecal retention, and interfere with the child's ability to sense the need to defecate. Moreover, if there is inadequate accompanying fluid intake, impactions can occur.
• Fluid intake: There is no evidence that constipation can be successfully treated by increasing fluid intake unless the patient is clinically dehydrated. To ensure adequate hydration, children with chronic constipation or fecal incontinence should be encouraged to consume at least 32 to 64 ounces (960 to 1920 mL) of water or other non-milk liquids per day, particularly if they are using fiber supplements.
• Cow's milk: In children whose constipation is unresponsive to other measures, and especially in those with atopic symptoms, we suggest a trial for at least two-weeks of eliminating all cow's milk protein from the diet.^(12,49,50) If the constipation improves substantially, the diet should be continued. A non-dairy form of milk (e.g. soy) can be used as a substitute.
• Probiotics: The evidence available from controlled trials in children and adults is insufficient to support a recommendation about use of probiotics to treat constipation in children, let alone identify the most effective strain, dose, or treatment duration.⁽¹²⁾ Different strains including but not limited to L reuteri, L. casei rhamnosus Lcr35, showed a beneficial effect in increasing bowel movement significantly.^(51,52)

GOALS OF THERAPY:

The goals in treating constipation are to produce soft, painless stools and to prevent the reaccumulation of feces.

GUIDELINES:

To view “Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN)”, please click on below link:

http://www.naspghan.org/files/documents/pdfs/cme/jpgn/Evaluation_and_Treatment_of_Functional.24.pdfTo view, “Managing functional constipation in children - Canadian Paediatric Society”, please click on below link:

http://www.cps.ca/documents/position/functional-constipationTo view, “Evaluation and Treatment of Constipation in Infants and Children – American Family Physician guidelines”, please click on below link:

http://www.aafp.org/afp/2006/0201/p469.htmlTo view, “Gastroenterology Organization Global Guidelines for the treatment of constipation”, please click on below link:

http://www.worldgastroenterology.org/guidelines/global-guidelines/constipation/constipation-english

CONSULTATION AND COUNCELLING:

Often, simple changes in diet and routine help relieve constipation in children:

• A high-fiber diet: A diet rich in fiber can help child's body form soft, bulky stool. The recommended intake for dietary fiber is 14 grams for every 1,000 calories in child's diet. For younger children, this translates to an intake of about 20 grams of dietary fiber a day. Offer child high-fiber foods, such as beans, whole grains, fruits and vegetables. But start slowly, adding just several grams of fiber a day over several weeks to reduce the amount of gas and bloating that can occur in someone who's not used to consuming high-fiber foods.
• Adequate fluids: Water and other fluids will help soften child's stool.
• Adequate time for bowel movements: Child should be encouraged to sit on the toilet for five to 10 minutes within 30 minutes after each meal. Follow the routine every day, even during holidays and vacations.

FOLLOW-UP:

The management of chronic constipation requires monitoring by the clinician or clinician's staff to prevent recurrences. Planned follow-up is particularly important during the first few days of treatment, especially if disimpaction was warranted. Patients who require disimpaction also should have an office visit soon after completing the disimpaction protocol to review the details of maintenance therapy.

After entering the maintenance phase, the child should have regular follow-up visits, initially on a monthly basis and then less frequently (e.g. every three to four months). The clinician should review the child's stool records and repeat the abdominal and rectal examinations. As laxative therapy is gradually discontinued, the importance of dietary and behavioral interventions should be reinforced.

PRECAUTIONS:

Please offer following advices to help prevent constipation in children:

• Offer your child high-fiber foods: Serve your child more high-fiber foods, such as fruits, vegetables, beans, and whole-grain cereals and breads. If your child isn't used to a high-fiber diet, start by adding just several grams of fiber a day to prevent gas and bloating.
• Encourage your child to drink plenty of fluids: Water is often the best.
• Promote physical activity: Regular physical activity helps stimulate normal bowel function.
• Create a toilet routine: Regularly set aside time after meals for your child to use the toilet. If necessary, provide a footstool so that your child is comfortable sitting on the toilet and has enough leverage to release a stool.
• Remind your child to heed nature's call: Some children get so wrapped up in in play that they ignore the urge to have a bowel movement. If such delays occur often, they can contribute to constipation.

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