Childhood constipation

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7309 (Published 13 November 2012)
Cite this as: BMJ 2012;345:e7309

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5 February 2014

Constipation is a common problem of childhood. [1] According to Avicenna's Canon of medicne, six essential schemes including air, foods and beverages, physical activity and rest, sleeping and awakening, retention and release as well as mental states should be observed to prevent constipation. Constipation or Ea'teghal-e-batn is a condition that the affected patients develop difficult or painful defecation. Dryness of food, low intake, dryness of gastrointestinal tract, excessive urination, excessive perspiration because of high temperature and exercise as well as intestine sensory loss are considered as the main causes of children constipation in Canon of medicine[2, 3]. High nutritional demands of children in spite of their immature GI tract prone them to developing dyspepsia and accordingly constipation. GI tract of children is considered very warm and wet. For this reason, they need very different nutritional foods. Recommended nutritional schemes in Traditional Persian Medicine (TPM) can prevent childhood constipation. Some fruits including banana, rape kiwi, potato, cucumber, palm, pear and the foods with difficult digestion are common causes of constipation in children[4].

Cold foods like ice cream, pickles and cold drinks are considered the causes of constipation in obese and inactive children. Causes of constipation in thin and active children comprise inobservance of the nutritional schemes and inadequate water drinking. The excessive exercises and not enough rest put them in the risk of developing constipation[3].

Treatment of constipation starts with dietary schemes, oil massages and then simple herbal medicines. Obese children should sleep less, exercise more and avoid eating dairy products with meals. Daily sleep and sleeping after meal and rest are not recommended to obese children. Thin children should sleep more and avoid activities that put them in the risk of excessive water loss[3]. Sweet almond, Taranjabin (Alhagi maurorum Medik), fig paste and flixweed are recommended emollient in children constipation[4-6]. Roasted meat pottage, Morri (a kind of pottage) and stew with tamarind are recommended foods for children prone to develop constipation[7]. Abdominal unction with sweet almond oil or olive and castor oil is also prescribed for affected children[5].

1. Auth, M.K.H., et al., Childhood constipation. BMJ, 2012. 345.
2. Majoosi Ahwazi A., Kamel-ol-Sanayeh-at-Tebbieh. 2008, Tehran: Jalal-ed-Din press.
3. Avicenna, H., Ghanoon Dar Teb [The Canon of Medicine], Bulaq Edition. Sharafkandi A, trans. Tehran: Univ of Tehran Pr, 1978.
4. Mozaffarpur, S., et al., Introduction Of Natural Medicinal Materia Effective In Treatment Of Constipation In Persian Traditional Medicine. MEDICAL HISTORY, 2012. 3(9): p. 79-95.
5. Hamedani, A.-I.-Z., Ehya-Al-Atfal Mozaffari. 2003, Tehran: Tehran University of Medical Sciences.
6. Mikaili, P., et al., Currently used traditional phytomedicines with hot nature in Iran. Annals of Biological Research Annals of Biological Research, 2011. 2(5): p. 56-68.
7. Kermani IN., Explaining the causes and signs (Sharh-ol-asbab va alamat). Vol. 2. 2008, Qom: Ehya-e-Tebb-e-Sonnati inistitue, Jalal-al-din press.

Competing interests: None declared

Majid Nimrouzi, PhD Candidate

Omid Sadeghpour, Mohsen Dehghani, Mohamad-Bagher Minaei

The School of Iranian Traditional Medicine, Tehran University of Medical Sciences, Tehran, Iran., Behesht Avenue. Tehran, Iran.

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17 November 2012

Every so often a review of childhood constipation is published (1,2,3,4). The discussion of psychological factors is invariably inadequate. The paper by Auth et al (4) is no worse than the others in this respect but prompts a long overdue examination of the language used and what it implies. One of these words is “functional”. In the 2010 review of NICE guidelines (2) the word used is “idiopathic”. It strikes me that these words are code for doctors giving up whilst pretending otherwise.

Auth et al report the cause of paediatric constipation to be “functional and multifactorial” in up to 90% of cases. Since everything is multifactorial I translate that word as “not amenable to justified oversimplification”.

Mayou and Farmer (5) tell us that the word “functional” means “unexplained by identifiable disease even after extensive medical investigation”. Extensive investigation must mean that knowledge, resources, or patience have been exhausted. Patience was not something we were encouraged to develop at medical school, and I believe this may be close to the crux of the matter. One can impatiently order a blood test, but one cannot impatiently take an effective history, and if one brings impatience into one’s dialogue with a child the results are rarely therapeutic. Standing impatiently over a child on the toilet doesn't work very well either.

Mayou and Farmer go on to say that their use of the word “functional...does not assume psychogenesis but only a disturbance in bodily functioning”. But a fracture disturbs the function of a leg; a tumour, the function of a brain. The word does not really signify, in this context, disturbance in bodily function. The conclusion that I draw is that the word here implies psychogenesis, whatever the protestations to the contrary, and the fact that we imply psychogenesis whilst denying that we are doing so contributes to the stigma around psychogenesis.

What is the excuse, in a clinical review of childhood constipation (and elearning module), for failing to enumerate some of the commoner psychological factors, how one might go about investigating them, or some information about behavioural or psychological interventions? A popular answer might be that there are insufficient high quality studies to justify setting this out in detail, but "moderate quality observational studies and the experience and opinion of the Guideline Development Group" were sufficient authority to instruct us under certain circumstances to announce “a positive diagnosis of idiopathic constipation” (2).

We are paralyzing ourselves and each other. We do not need randomized control trials to know that it is good practice to understand what we mean by the words we use, and to make sufficient effort to understand our patient.

A child’s constipation might be caused or contributed to by, for example, a fear of sitting on the toilet, or an inchoate anger. There is no shame in that.

There is no excuse, though, for skating over psychological causation and management in a review on childhood constipation and that is where the shame comes in. We are ashamed of the fact that a) we can’t explain everything, b) we can’t cure everything, and c) we are too busy to spend time with the child. We then project that shame onto the child and family and obscure the situation with jargon to give everyone the impression that we are protecting their shame rather than our own.

I suggest we stop being ashamed of knowing that something is worth doing even though it is difficult to prove to a cynic; stop being ashamed of the fact that often our most valuable investigative tools are time, patience and interest; and stop writing reviews on the management of childhood constipation that coyly refer to emotional and psychological processes as though they are somehow not our business(6 ).

1) Rubin G. Dale A. Chronic constipation in children. BMJ. 2006.333: 1051–1055 (18 November)

2) Bardisa-Ezcurra L. Ullman R. Gordon J. Diagnosis and management of idiopathic childhood constipation: summary of NICE guidance. BMJ 2010;340:c2585 (1 June)

3) Tabbers M. Boluyt N. Berger M. Benninga M. Nonpharmacological Treatments for Childhood Consipation: Systematic review. Paediatrics 2011;128; 753 (26 September).

4) Auth M. Vora R. Farrelly P. Baillie C. Childhood constipation. BMJ 2012;345:e7309 (13 November)

5) Mayou R. Farmer A. ABC of psychological medicine
Functional somatic symptoms and syndromes. BMJ 2002;325:265 (3 August)

6) Holzwarth W. Erlbruch W. The story of the little mole who knew it was none of his business. Pavilion Children's Books. Sept 1994

Competing interests: None declared

Andrew F West, Child and Adolescent Psychiatrist

Berkshire Healthcare NHS Foundation Trust, Reading CAMHS and PPALS, 3 Craven Rd, Reading, Berkshire, RG1 5LF

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